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Based on policy review, medical record review, and staff interview the hospital failed to ensure staff monitored a restrained patient per policy for 4 of 5 sampled restrained patients (#2, 3, 4, & 5).

The findings include:

Review of current hospital policy entitled "Restraints, Non emergent and emergent" dated 05/10/2010 revealed, under 4. "Assessment, Monitoring, and Intervention..."At a minimum, a patient in restraints is monitored every two (2) hours and the need for restraint assessed daily by an RN (registered nurse)....Patient level of distress and agitation, mental status, cognitive functioning, vital signs, Hydration, nutritional and elimination needs, Positioning needs, range of motion, circulation and skin condition" are to be checked.

1. Open medical record review on 9/14/2010 for Patient #2 revealed a 75 year old male admitted to the the hospital on 9/3/2010 for Respiratory Failure, COPD (Chronic Obstructive Pulmonary Disease and S/P (status post) Tracheostomy. Record review revealed the patient was on a ventilator. Record review revealed the patient was placed in soft upper extremities restraints on 9/3/2010 at 1130. Record review revealed no documentation staff monitored the patient every 2 hours while in restraint per policy. Record review revealed no documentation staff assessed the patient's level of distress and agitation, mental status, cognitive functioning, vital signs, hydration, nutritional and elimination needs, positioning needs, range of motion, circulation, and skin condition on 9/4/2010 between 1800 and 1204 on 9/5/2010 (18 hours); on 9/5/2010 between 1204 and 1604 (4 hours); on 9/5/2010 between 1808 and 1115 on 9/6/2010 (17 hours); and on 9/12/2010 between 0649 and 1123 (4 hours and 34 minutes).

Interview on 9/15/2010 at 1330 with the hospital nurse manager revealed a new computer system was now being used and at this time it doesn't seem to be working appropriately thus the documentation may be inaccurate. Interview confirmed there was no available documentation staff assessed the patient every 2 hours while in restraint.

2. Open medical record review on 9/14/2010 for Patient #3 revealed a 76 year old male admitted to the the hospital on 8/10/2010 for Respiratory Failure, Trauma, Subarachnoid Hemorrhage and S/P (status post) Tracheostomy. Record review revealed the patient was placed in soft upper extremities restraints on 8/27/2010 at 1000. Record review revealed no documentation staff monitored the patient every 2 hours while in restraint per policy. Record review revealed no documentation staff assessed the patient's level of distress and agitation, mental status, cognitive functioning, vital signs, hydration, nutritional and elimination needs, positioning needs, range of motion, circulation, and skin condition on 09/02/2010 between 0306 and 0800 (5 hours and 6 minutes); on 09/03/2010 between 1800 and 2400 (6 hours); on 9/4/2010 between 1600 and 2400 (8 hrs)on 09/05/2010 between 0000 and 0800(8 hours); on 09/06/2010 between 1600 and 2000 (4 hours); and on 09/08/2010 between 0800 and 2000 (12 hours).

Interview on 9/15/2010 at 1330 with the hospital nurse manager revealed a new computer system was now being used and at this time it doesn't seem to be working appropriately thus the documentation may be inaccurate. Interview confirmed there was no available documentation staff assessed the patient every 2 hours while in restraint.

3. Open medical record review on 9/14/2010 for Patient #4 revealed a 51 year old male admitted to the the hospital on 9/10/2010 for Respiratory Failure and Chronic Deconditioning. Record review revealed the patient was placed in soft upper extremities restraints on 9/12/2010 at 0900. Record review revealed no documentation staff monitored the patient every 2 hours while in restraint per policy. Record review revealed no documentation staff assessed the patient's level of distress and agitation, mental status, cognitive functioning, vital signs, hydration, nutritional and elimination needs, positioning needs, range of motion, circulation, and skin condition on 09/12/2010 between 0649 and 1123 (4 hours and 34 minutes).

Interview on 9/15/2010 at 1330 with the hospital nurse manager revealed a new computer system was now being used and at this time it doesn't seem to be working appropriately thus the documentation may be inaccurate. Interview confirmed there was no available documentation staff assessed the patient every 2 hours while in restraint.

4. Closed medical record review on 9/15/2010 for Patient #5 revealed a 73 year old female admitted to the the hospital on 8/25/2010 for Respiratory Failure, SOB (Shortness of Breath), Pulmonary Contusion & Hemorrhage, COPD (Chronic Obstructive Pulmonary Disease), and Hospital acquired Pneumonia. Record review revealed the patient was on a ventilator. Record review revealed the patient was placed in soft upper extremities restraints on 8/27/2010 and remained in restraints until she expired on 8/31/2010 at 2207. Record review revealed no documentation staff monitored the patient every 2 hours while in restraint per policy. Record review revealed no documentation staff assessed the patient's level of distress and agitation, mental status, cognitive functioning, vital signs, hydration, nutritional and elimination needs, positioning needs, range of motion, circulation, and skin condition on 8/28/2010 between 0800 and 1200 (4 hours), 1200 and 1706 (5 hours and 6 minutes), and 1706 and 2155 (4 hours and 49 minutes); on 8/29/2010 between 0000 and 0455 (4 hours and 55 minutes), 0455 and 0830 (3 hours and 35 minutes), 0830 and 1130 (3 hours), and 1130 and 2000 (8 hours and 30 minutes); and on 8/30/2010 between 0000 and 0800 (8 hours), 0800 and 1200 (4 hours), 1200 and 1723 (5 hours and 23 minutes) and 1723 and 2116 (3 hours and 53 minutes).

Interview on 9/15/2010 at 1330 with the hospital nurse manager revealed a new computer system was now being used and at this time it doesn't seem to be working appropriately thus the documentation may be inaccurate. Interview confirmed there was no available documentation staff assessed the patient every 2 hours while in restraint.

Based on medical record review and administrative staff interview the hospital staff failed to report the death of a patient that occurred while patient was in restraints to the Centers for Medicare Services (CMS) for 1 of 1 sampled patients that expired while in restraint (#5).

The findings include:

Closed record review for Patient #5 revealed a 73 year old female admitted on 8/25/2010 at 1320 for the treatment of respiratory failure, pulmonary contusion and hemorrhage, COPD (Chronic Obstructive Pulmonary Disease), and hospital acquired pneumonia. Record review revealed the patient was on a ventilator. Record review revealed the patient had been placed in SPD (soft protective device) bilateral wrist restraints to prevent patient from pulling at IV (intravenous tubings) and ventilator tubings per physician's order on 8/27/2010. Record review revealed the patient expired on 08/31/2010 at 2207. Record review revealed the patient remained in restraints until the time of death. Further record review revealed no available documentation the patient's death while in restraints was reported to CMS.

Interview with the Quality Control manager/director on 9/15/2010 at 1030 revealed the hospital had no guidelines or policy addressing the death of a patient while in restraints. Interview revealed the hospital did not have a process in place to report restraint deaths to CMS. Interview revealed the hospital did not report Patient #5's death in restraints to CMS.

Based on review of the hospital's medical staff by-laws, credential file review and staff and physician interview, the hospital failed to ensure 1 of 1 sampled physicians with temporary privileges met the required qualifications set forth in the medical staff bylaws (Physician #1).

The findings include:

Review of the medical staff by-laws, revised 03/05/2010, revealed "...Article 6 Clinical Privileges...6.3 Temporary Clinical Privileges 6.3.1 Membership Application Pending Temporary Clinical Privileges are granted by the Chief Executive Officer upon recommendation of the President or designee for the care of patients to a practitioner who is an applicant for membership....The applicant shall provide a current State license, current DEA registration...."

Review on 09/15/2010 of Physician #1's credential file revealed the physician was granted temporary privileges on 08/23/2010. Review of the credential file revealed a "Temporary Privileges Approval Notification" signed by the Hospital's Chief Executive Officer and the Medical Staff President on 08/19/2010. Review of the notification revealed "...The Credential file of the above referenced practitioner is complete, it contains all information required by the Medical Executive Committee to make a favorable recommendation to the Governing Board to approve a request for medical staff membership and clinical privileges. There are no adverse findings contained in the file and a positive outcome is expected. The duration of your temporary membership/privileges may not exceed 90 days and will extend From 08/23/10 To 11/23/10." Review of Physician #1's credential file revealed no evidence of a current DEA (Drug Enforcement Administration) registration.

Interview on 09/15/2010 at 1515 with the director of health information management revealed the director was responsible for credentialing physicians. Interview confirmed Physician #1 was granted temporary privileges on 08/23/2010. Interview confirmed Physician #1 did not have a current DEA registration. Interview revealed, "I didn't know our by-laws required a DEA for temporary privileges."

Interview on 09/16/2010 at 0930 with the President of the medical staff revealed Physician #1 is contracted through the company that provides the hospitalist service. Interview revealed Physician #1 has applied for a DEA certificate. Interview further revealed, "I was told by the contract company that he had a DEA certificate. Obviously, he did not....He should not have been granted temporary privileges without a current DEA registration." Interview further revealed, "I have asked him not to come back until he has one."