HospitalInspections.org

Based on hospital document review, medical record review, and staff interviews, the hospital failed to ensure that each patient or patient representatives were informed of the patient's rights. This occurred in 7 (#2, 3, 4, 6, 8, 9, and #11) of 11 medical records reviewed.

Findings:
1. On the morning of 02/11/2015, surveyors reviewed medical records. 7 (#2, 3, 4, 6, 8, 9, and #11) of 11 medical records reviewed did not contain documented evidence that patients received their patient rights. These findings were verified by Staff G.

2. The "Emergency Authorization and Consent to Treat" document did not inform patients and or patient representatives of all required patient rights. This was verified by the CEO.

3. The "Emergency Authorization and Consent to Treat" document did not contain documented evidence for patient consent for medical treatment. This was verified by the CEO.

4. The "Emergency Authorization and Consent to Treat" document did not contain documented evidence to consent to be photographed. This was verified by the CEO.

5. On the morning of 02/11/2015, surveyors requested the hospital's restraint policy and procedure. On the afternoon of 02/11/2015, the CEO provided a document titled, "Restraint and Seclusion Policy."

6. The policy and procedure documented, "...Psychiatric Service..." and did not document the use of restraints for medical conditions. On the afternoon of 02/11/2015, the CEO told surveyors that the "Restraint" policy he provided to the surveyor is the hospital's current restraint policy and procedure that is used facility wide.

7. The CEO told surveyors the hospital does not utilize seclusion in the facility and that the policy and procedure was incorrect and the hospital gets their hospital policies from the corporate office which is located in a different state.

8. There was no documented evidence that policies protecting patient rights were formulated by the medical staff and administration of the hospital. The CEO informed surveyors that the corporate office in another state and the corporate office developed policies and procedures for the facility.

Based on policy and procedure review, medical record review, and staff interviews, the hospital failed to ensure that there were appropriate policies and procedures regarding the use of physical and chemical restraints.

Findings:

1. On the morning of 02/11/2015, surveyors requested the hospital's restraint policy and procedure. On the afternoon of 02/11/2015, the CEO provided a document titled, "Restraint and Seclusion Policy."

2. The policy and procedure documented, "...Psychiatric Service..." and did not document the use of restraints for medical conditions.

3. On the afternoon of 02/11/2015, the CEO told surveyors that the "Restraint" policy he provided to the surveyor is the hospital's current restraint policy and procedure that is used facility wide.

4. The "Restraints and Seclusion" policy and procedure documented, "...Seclusion/restraint usage is limited to those situations in which all less restrictive measures have been unsuccessful...to the milieu..." The term milieu is typically referred to a social environment of psychotherapy. On the afternoon of 02/11/2015, the CEO verified that the hospital's policy and procedure for restraints and seclusion was not appropriate for their facility.

5. On the morning of 02/11/2015, Staff G, Staff, S, and Staff T, all nurses, verified that the hospital restraint and seclusion policy and procedure does not address the use of restraints for medical reasons.

6. On the morning of 02/11/2015, surveyors reviewed 4 (#3, 4, 5, and #7) of 4 medical records that had orders for restraints. All 4 medical records documented "soft limb restraint."
All 4 medical records did not specify what limb(s) were being restrained.

7. On the morning of 02/11/2015, Staff G, Staff S, and Staff T, all nurses, verified that there was no documented evidence on the medical/surgical restraint order which limb(s) were to be restrained. Staff G, Staff S, and Staff T told surveyors that they assumed the physician mean both arms.

8. On the afternoon of 02/11/2015, surveyors requested the hospital's policy and procedure for telephone/verbal orders. The CEO provided a policy titled, "Time Frames" that documented, "Verbal Orders Per state law OK-48 hours."

9. On the afternoon of 02/11/2015, The CEO told surveyors that the "Time Frame" policy specifically states physicians have up to 48 hours to sign their orders.

10. The CEO and HIM Manager verified that 4 (#3, 4, 5, and #7) of 4 medical records reviewed that contained telephone/verbal orders for restraints were not signed by the physician. The CEO and HIM Manager verified that all 4 medical records reviewed containing orders for restraints did not have documented evidence of a signature from the ordering physician and was not done in a timely manner per hospital policy.

11. There was no documented evidence that the QAPI looked at restraints with meaningful use, analyzing the entire restraint process to include restraint policy, restraint orders, and accurately tracking restraints.

12. The "Restraints and Seclusion" policy and procedure documented, "...Restraint and seclusion activities are integrated in the program Performance Improvement activities..."
There was no documented evidence that the QAPI (Quality Assessment Performance Improvement) program looked at seclusion activities.

13. On the afternoon of 02/11/2015, the Quality/Risk manager told surveyors that seclusion activities are not looked at.

14. The CEO told surveyors the hospital does not utilize seclusion in the facility and that the policy and procedure was incorrect, that their hospital gets their hospital policies from the corporate office which is located in a different state.

Based on document review and staff interview, it was determined the hospital failed to ensure nursing staff administered drugs and biologicals according to hospital's policies and procedures. This occurred in two (# 8 and 9) of eleven patient medical records reviewed.

Findings:

Medical records were reviewed on the afternoon of 02/11/15.

A hospital policy titled, Intravascular (IV) Therapy, documented, "...The following nursing interventions may not be delegated in an practice setting: vii. Administration of medications requiring both titration and continuous patient assessment;..."

Patients # 8 and 9 were both inpatients in the High Observation Unit (HOU).

Patient # 8 received Diprivan and Cardizem, both were administered IV and titrated as needed (PRN). Review of the medical record contained documentation of a Licensed Practical Nurse (LPN) titrating both medications. This was confirmed by Staff A during medical record review.

Patient #9 received Diprivan and Levophed, both were administered IV and titrated PRN. Review of the medical record contained documentation of a LPN titrating both medications. This was confirmed by Staff A during medical record review.