HospitalInspections.org

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Based on personnel file review and interview, the hospital failed to verify current credentials for all practitioners providing patient care.

Failure to verify current credentials for medical staff puts patients at risk of harm from inadequate or substandard care.

Findings included:

1. Investigator #4 completed a document review of the personnel files for 5 on-site medical practitioners and 2 tele-medicine practitioners. The review showed:

a. The facility's credentialing file for 1 of 7 practitioners, whose most recent appointment began on 07/29/17, showed a state license with an expiration date in 2018. The investigator's onsite review of the primary source verification showed the practitioner had a state license with an expiration date of 06/11/20.

b. The facility's credentialing file for 1 of 7 practitioners whose most recent tele-medicine appointment began on 04/16/18, showed a U.S. Drug Enforcement Agency (DEA) number with an expiration date of 03/31/19. The investigator's onsite review of the primary source verification showed an expiration date of 03/31/22.

2. On 04/17/19 at 9:45 AM after completing the document review, Investigator #4 interviewed a member of the facility's corporate support service (Staff #401) about the hospital's process for medical staff credentialing. The staff member stated that the hospital's corporate offices use a medical staff program subscription service that is designed to complete "real-time" updates for staff credentials. She also stated the system is monitored daily and staff produce a monthly report. She stated that her review of the practitioner's state licensing information showed that the physician's file was "taken out of use". She stated that she did not know how it occurred. She also stated that she was unable to determine why the tele-medicine practitioner's file was not updated to reflect his most current DEA status.
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Based on record review, interview, and review of hospital policy and procedure, the hospital failed to modify the patient's plan of care after placing patients in restraints for 3 of 8 records reviewed. (Patient #903, #904 and #905)

Failure to modify plans of care for patients placed in restraints risks patient safety due to not meeting the patient's physical and emotional needs.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion," policy number H-PC 07-009, release date 06/17, showed that once the patient is restrained, the registered nurse (RN) modifies the patient's care plan after daily assessment and review.

2. On 02/18/19, Investigator #9 reviewed restraint records and found the following:

a. Patient #903 with no documentation of daily restraint care plan review on 02/21/19, 03/02/19, 03/03/19, and 03/04/19.

b. Patient #904 with no documentation of daily restraint care plan review on 02/15/19.

c. Patient #905 with no documentation of daily restraint care plan review on 04/15/19 and 04/16/19.

3. On 04/18/19 at 1:00 PM, Investigator #9 interviewed the acting Chief Nursing Executive (Staff #901) regarding the missing care plan documentation. She stated that hospital policy regarding care plan documentation review was not followed.
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Based on record review, interview, and review of hospital policy and procedure, the hospital failed to ensure that a licensed provider wrote an order for restraints for 2 of 4 restraint episodes for Patient #902.

Failure to ensure that a provider writes an appropriate order for restraint risks psychological harm, loss of dignity and personal freedom.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion," policy number H-PC 07-009, release date 06/17, showed that a physician or Licensed Independent Practitioner (LIP) may order use of non-violent restraints for up to seven days. After seven days, a new order is required for continued restraint use, as well as a Registered Nurse (RN) safety assessment 30 minutes post restraint application.

2. On 04/18/19, Investigator #9 reviewed the seclusion records for Patient #903. The review showed that restraints were reapplied after the patient attempted to pull out life-saving medical devices. Investigator #9 found that physician orders were missing for the dates of 02/25/19 and 03/02/19. Additionally, there was no record of the RN assessment of the patient following restraint application.

3. On 04/18/19 at 1:00 PM, Investigator #9 interviewed the acting Chief Nursing Executive (Staff #901) regarding the missing orders for restraints and missing RN assessments. She stated that the hospital policy for restraints was not followed and the RN safety assessment documentation not completed.
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Based on record review, interview, and review of hospital policy and procedure, the hospital failed to ensure that staff monitored patients placed in restraints as directed by hospital policy for 3 of 8 restraint records reviewed. (Patient #903, #904, and #906)

Failure to monitor patients who are restrained puts them at risk for injury.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion," policy number H-PC 07-009, release date 06/17, showed that the RN will at least every 2 hours, assess the circulatory status of restrained extremities and pain management status.

2. On 04/18/19, Investigator #9 reviewed restraint records and found the following:

a. Record review for Patient #903 showed the RN failed to document circulatory status of extremities and pain management on the following date and times:

02/15/19 at 8:15 AM, 10:15 AM, 12:15 AM, 2:00 PM, 4:00 PM and 6:00 PM.

b. Record review for Patient #904 showed the RN failed to document circulatory status of extremities and pain management on the following dates and times:

02/14/19 at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM,

02/15/19 at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM,

02/25/19 at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM.

c. Record review for Patient #906 showed the RN failed to document circulatory status of extremities and pain management on the following dates and times:

03/17/19 at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM,

04/11/19 at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM.

3. On 04/18/19 at 1:00 PM, Investigator #9 interviewed the acting Chief Nursing Executive (Staff #901) regarding the RN monitoring the patient's circulatory status of restrained extremities and pain management. She stated that hospital policy for restraints and RN assessment was not followed.
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Based on record review, interview, and document review, the hospital failed to ensure that providers followed the medical staff rules and regulations.

Failure to document a provider's assessment, evaluation, and treatment following a patient's medical emergency decreases the quality of the information the hospital can provide for ongoing treatment of the patient.

Findings included:

1. Document review of the hospital document titled, "Kindred Hospital Seattle-Northgate & Kindred Hospital Seattle-First Hill- 2016 Medical Staff Rules & Regulations," showed that pertinent progress notes of patient observations shall be recorded documenting changes, updates, and modifications of the treatment plan.

Consultations shall be documented in the electronic record and show pertinent findings on examination of the patient, the consultation's opinion, and recommendations.

Document review of the hospital document titled, "Physician Coverage Agreement Kindred Hospital," showed that each physician shall promptly and accurately document the services provided to each patient in the patient's record.

2. On 04/17/19 at 9:30 AM, Investigator #3 and the Director of Nursing and Clinical Services at Northgate Campus (Staff #301) reviewed the medical record of Patient #301 who was admitted on 04/08/19 for acute respiratory failure. The record review showed:

- A rapid response team (RRT) activation was initiated on 04/08/19 at 8:05 PM for a heart rate of 204. The RRT event ended at 10:07 PM. The telemedicine physician (Staff #302) was notified at the time of the activation. The Intensivist (Critical Care Physician) (Staff #303) was notified at 8:10 PM. Interventions ordered included multiple administrations of intravenous medications, 12-lead electrocardiogram, blood glucose test, scan of urinary bladder, and urethral catheter insertion. No physician progress note was documented in the medical record for this event.

- A rapid response team activation was initiated on 04/09/19 at 8:09 PM for increased heart rate. The RRT event ended at 9:40 PM. The telemedicine physician (Staff #304) was notified at the time of activation. The Intensivist (Staff #303) was notified at 8:45 PM. Patient #301 was again given multiple intravenous medications. No physician progress note was documented in the medical record for this event.

Staff #301 confirmed the above findings at the time of review.

3. On 04/17/19 at 11:30 AM, Investigator #3 interviewed the Kindred Hospital-Northgate Campus attending physician (Staff #305) about expectations for physician documentation. Staff #305 stated that whenever there is a significant change in the patient's condition, a physician progress note should be written. He confirmed a progress note should have been written after Patient #301's two RRT activation events.