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Based on record review, policy review, observation and interview, it was determined the facility failed to protect and promote the rights of patients as evidenced by:

1. Failure to provide the Important Message from Medicare (A-0117)

2. Failure of the governing body to ensure the effective operation of grievance
process (A-0119)

3. Failure to provide a written letter of resolution (A-0123)

4. Failure to obtain consent for the administration of blood products (A-0131)

5. Failure to ensure the proper orders for restraints (A-0154)

6. Failed to ensure that all staff are trained in the use of restraints (A 0199)

7.Failure to provide the appropriate education and training for the use of restraints (A-0208)

Based on record review and interview the facility failed to ensure that the Important Medicare Message (IMM) was provided to the patients within two days of admission to the facility and prior to discharge from the facility in 7 of 12 patients (#4, #5, #7, #12, #14, #19 and #21) resulting in the potential of denying the patient the right to receive Medicare covered services post discharge, the right to be informed of who will pay for services, where they may get those services, to be involved in any decisions about their hospital stay, who will pay for their stay, and report any concerns about quality of care to the Quality Improvement Organization (QIO) MPRO, to be involved in their discharge planning, and to appeal discharge plans if the patient thought they were being discharged too soon.

During record review on 8/2/2011 at approximately 1300 it was revealed that the IMM was not provided to patients #12 and #14 prior to discharge. This was confirmed with the chief clinical officer and the vice president on 8/2/2011 at approximately 1400.

An interview was conducted with the chief clinical officer and the vice president of nursing where it was confirmed that neither patient received a second notice of the IMM prior to discharge. The chief clinical officer stated "it is the practice that the same IMM is pulled from the patient's chart and signed again at which time a copy is made for the patient and given to the patient".



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During review of the medial record for patients #4 on 08/02/2011 it contained an IMM dated 03/02/2011. The patient was admitted to the facility on 02/19/2011 and was still an inpatient at the time of the survey.
Review of the medical record for patient #5 on 08/02/2011, revealed an IMM dated 02/03/2011. The patient was discharged on 02/17/2011 without the 2nd IMM being provided to the patient and/or the patient representative.
Review of the medical record for patient #7 on 08/02/2011, revealed that the patient was admitted to the facility on 05/03/201. The patient record contained an IMM that was not dated. The record also lacked a 2nd IMM when the patient was discharged on 05/09/2011.
Review of the medical record for (in)patient #19 on 08/02/2011, revealed that the record contained an IMM that was not dated. Survey was unable to determine from the lack of documentation if the IMM was completed within two days of of the patient being admitted to the facility or not.
Review of the medical record for patient #21 on 08/02/2011 revealed that the patient was admitted on 01/19/2011. the 1st IMM was signed by the patient's wife on 01/20/2011. The patient was discharged from the facility on 04/14/2011. The medical record did not contain documentation of a 2nd IMM being given at the time of discharge.

The above findings were all reviewed with and confirmed by the Director of Quality on 08/02/2011. The facility was unable to locate any further IMM documents for the above patients.

Based on policy review, record review and interview, the governing body failed to ensure that the facility had an effective grievance committee. Findings include:

Review of Vibra policy titled Patient Complaint and Grievance Process policy #ADM 213 approval date of 10/14/2010, it reads under #13 that written response, including notice of the steps taken to investigate the grievance is provided to complainants.

During review of the complaint/grievance log with the Director of Risk Management on 08/02/2011 at 1000, it was noted that the log contained several documented entries of grievances. The log further lacked documentation of the patient being sent a written response. During the review, the Director of Risk management was queried as to if the complainants had received a written response as per Vibra policy. The reply from the Risk Manager was "No, these are not all grievances, the person placing the information into the log book did not do it correctly."

Based on policy review, record review and interview, the facility failed to provide written resolutions to patient's grievances. Findings include:

Review of Vibra policy titled Patient Complaint and Grievance Process policy #ADM 213 approval date of 10/14/2010, under #13 it states the written response, including notice of grievance resolution and decisions made is provided to complainants.

Review of the complaint/Grievance log on 08/02/2011 at 1000 with the director of Risk Management revealed several documented entries in regards to receipt of written grievances. The area on the log for documenting the date a resolution letter was sent to the complainant was blank. When the Director of Risk Management was queried about if the patient received a letter of not she replied "the documentation in the log is incorrect, the staff placing the entries into the log did not understand; therefore she did not do it correctly." She stated that "not all of the entries documented as written grievances were grievances."
Two of the entries that were confirmed written grievances by the Director of Risk Management had not received written responses per policy.

Based on record review, policy review, and interview it was determined that the facility failed to obtain a consent for blood administration prior to administering blood products in 1 of 1 patients (#11) resulting in the potential of violating the patient's right to refuse the blood products and the potential to violate the patient's religious practice.

On 8/2/2011 at approximately 1120 it was revealed that blood was administered to the patient without prior consent being obtained. This was confirmed by the vice president of nursing and the chief clinical officer.

On 8/2/2011 at approximately 1500 a policy # PCNUR 070 titled "Blood Product Administration" was reviewed and revealed that the facility failed to follow the policy that "an informed consent must be obtained prior to the administration of blood/blood products".

On 8/2/2011 at approximately 1400 an interview was conducted with the chief clinical officer at which time she confirmed that "all" blood transfusions must have consent whether it be from the patient or patient's the medical power of attorney.

Based on medical record review and interview the facility failed to ensure the appropriate use of restraints according to orders for 3 of 5 patients (patient #1,#2,#17) resulting in the potential to restrain the patient inappropriately.

On 8/1/2011 at approximately 1100 during medical record review it revealed that patient #1 had an altered restraint order in which a vest had been added to the order without proper physician signature or an additional order in the patient's chart. The addition of the vest was initialed by the house physician sometime after the initial order without date, time, or signature on 7/29/2011. Further review of the patient's chart revealed that on 7/30/2011 the facility failed to obtain an order for a vest restraint and the order was for only the use of soft limb x 2 restraints. A fall report dated 7/31/2011 at 0000 listed the patient was found with vest restraint and soft limb x 2 restraints in use at the time of the fall.

On 8/1/2011 at approximately 1130 during medical record review it revealed that patient #2 had a restraint order dated 7/23/2011 that failed to contain the ordering physician's signature. This was confirmed by the chief clinical officer that the order had not been authenticated by the physician.

On 8/2/2011 at approximately 0900 during medical record review of patient #17 it revealed that restraint order form dated for 8/2/2011 had not addressed: 1. less restrictive intervention used/considered that are ineffective, and 2. reason for the use of restraint. The order form was signed and dated by the physician on 8/2/2011 at 1005. This was confirmed by the chief clinical officer that the form failed to be filled out in its entirety.

On 8/2/2011 at approximately 1030 an interview with the chief clinical officer and vice president of nursing confirmed that the restraint orders for patients #1,#2, and #17 had not been executed correctly.

Based on employee record review and interview the facility failed to provide the proper education, training, and return demonstration for 2 of 8 nursing staff members and 2 of 6 agency nursing staff members to ensure the proper knowledge and use of restraints resulting in the potential for patient harm not limited to patient death.

On 8/2/2011 at approximately 1000 during the review of staff education charts it was revealed that all nursing staff members did not receive proper training for the use of restraints. Nursing staff members #N and #O had not completed restraint training as part of the required orientation for new nursing employees. Agency staff members #T and #U did not have any restraint training documented in either of their education folders. This was confirmed with the interim human resource director, clinical educator, and chief clinical officer.

On 8/2/2011 at approximately 1045 an interview took place with the vice president of nursing, chief clinical officer, corporate compliance officer and clinical educator at which time it was stated that restraint training should be done on an annual basis. The chief clinical officer stated that "annual restraint training has not been done since I did it in 2008".