CMS-LewisGale-Hospital-Montgomery

Based on record review and interview, it was determined that facility staff failed to ensure that nine (9) of fourteen (14) patients who experienced behavioral health emergencies and required one on one (1:1) sitters during their care, were provided 1:1 sitters per hospital policy, and in a manner to protect their safety. (Patients # 3, 6, 7, 8, 9, 12, 16, 17, and 18).

Findings included:

Patient #3 arrived in the facility's hospital emergency department (ED) voluntarily, accompanied by police for suicidal ideations. Patient #3 was initially detained with an emergency custody order (an ECO is a legal order by the court which authorizes law enforcement agencies to take a person into custody for a mental health evaluation by a qualified mental health professional (QMHP)), but became voluntary by willing to accept treatment after being brought to the ED, so police did not stay with the patient after the ECO ended.

During an interview of 12/10/19 at 10:40 a.m., Registered Nurse (RN) #6 told the surveyor that all psychiatric (psych) patients are considered level 2, because they require a higher level of attention, but not all psych patients get an order for 1:1 sitters. RN #6 stated Because [this patient] came in with cutting behavior, that would make [patient] 1:1. I don't see a 1:1 order in the history. RN #6 told the surveyor that 15 minute checks did not start as soon as they should have. Every 15 minute checks started being documented at 8:00 a.m., a sitter was called to stay with the patient at 8:49 a.m., within line of site. A note at 3:00 a.m. evidenced that the police officer was not present, RN #6 said I don't know when the officer left.

Patient #6 arrived in the ED voluntarily, accompanied by parents, with complaints of suicidal ideation (SI), with a plan, and a history of SI and self-harm. The initial triage suicide assessment of Patient #6 evidenced documentation that the patient was at risk for suicide. Safe environment was documented by the ED RN on 11/8/19 at 12:54 p.m.

Nursing notes by ED RN at 12:48 p.m. on 11/8/19 documented that Patient #6's parents were at the bedside.

The record evidenced a behavioral health assessment summary of clinical presentation which recommended inpatient treatment due to SI with plan, and intent, that patient was a safety risk, and that Patient #6 was medically cleared for admission to an adolescent psych unit.

Patient #7 presented to the ED with an ECO, accompanied by police, with diagnosis of depression.

There was no order for a 1:1 sitter; however, there was documentation on 11/15/19 of a sitter by the bedside. RN #6 was unable to tell the surveyor if a sitter was in place prior to police leaving the bedside, based on documentation in the record. Patient #7 was discharged to the care of parents, with a signed safety plan contract.

Patient #8 presented to the ED with an ECO, accompanied by police, with diagnosis of threatened overdose. Evaluation by a QMHP recommended inpatient psych treatment, 1:1 safety attendant, ED behavioral health room, and environmental safety check. Documentation in the record evidenced that Patient #8 attempted to leave the ED, and was escorted back into the room by police and security. Patient #8 became combative and an intramuscular (IM) injection of Geodon (Geodon IM works quickly to reduce tension and anxiety, and is intended for short-term control of severe occurrences of agitation in schizophrenia). Patient #8 was medically cleared and transferred to a psych hospital. Patient #8 did not have an order for 1:1 sitter, and the record lacked documentation that a sitter was present.

Patient #9 presented to the ED as a walk-in to have medical clearance for inpatient psych admission. Patient #9 was sent from school by CSB counselor, with diagnosis of SI and hallucinations. Patient #9 was accompanied to the ED by their grandmother, as a voluntary admission. CSB Risk assessment details evidenced documentation that Patient #9 had been hospitalized twice within the past 60 days, and has endorsed both auditory command hallucinations and visual hallucinations of a demon. [Patient] believes that [patient] could become possessed at any time and kill [self] or someone in [patient's] family. CSB supplemental information evidenced documentation that if the patient or guardian changed their minds about voluntary admission, TDO criteria can be met and client would be a TDO. (Temporary Detention Order (TDO) is a legal document which requires individuals to receive immediate hospitalization for further evaluation and stabilization on an involuntary basis).

The nursing triage note evidenced documentation that Patient #9 was at risk of suicide, and that an environmental safety check was performed. There were no orders for suicide precautions or 1:1 sitter noted in the medical record. RN #6 was interviewed on 12/10/19 between 1:40 p.m. and 2:00 p.m., and confirmed to the surveyor that they didn't see an order for suicide precautions or for level of observation (1:1 sitter, line of site, direct observation, etc) in the order history. RN #6 also stated I know for peds [pediatrics] they have to have somebody with them, but I can't find where it's documented that somebody is with [patient]. RN #6 told the surveyor that the record lacked evidence that every 15 minute checks were performed, as well as documentation that the grandmother was with the patient, and that they would like to see that note. Patient #9 was medically cleared and transferred to a psych hospital, after a bed was secured.

Patient #12 presented to the ED via EMS due to overdose(OD)/attempted suicide. The medical record review revealed a physician order for 1:1 sitter written at 7:29 p.m. on 11/26/19. Documentation of 1:1 sitter did not begin until 11/26/19 at 10:00 p.m. RN #6 was navigating the medical record with the surveyor, and stated an OD would have gone in room 1, 2, or 3, so we could watch them. Patient #9 was transferred to the intensive care unit (ICU) at 12:30 a.m. on 11/26/19.

Patient #16 presented to the ED as a walk-in, accompanied by their guardian, with diagnosis of bizarre behavior and SI. The ED clinician documented that Patient #16 was delusional and paranoid. The triage nursing assessment evidenced documentation that Patient #16 was at risk for suicide. Suicide precautions and secured patient belongings were documented on 10/28/19 at 11:58 a.m. Safe environment, bed 12, with guardian was documented. At 11:00 a.m. on 12/11/19, RN #6 was navigating record with the surveyor, and said [Patient] is on 1:1 and [patient] is with parent. At 5:09 p.m. on 10/28/19 a RN documented that they stayed with Patient #16 after the parent requested to leave the room to get fresh air. A behavioral health evaluation was performed, Patient #16 was medically cleared, and the patient was transferred to an inpatient psych facility for treatment.

The surveyor interviewed RN #6 on 12/11/19 at 11:02 a.m. and inquired about the facility's suicide precaution policy which states that family members may be utilized for observation of suicidal patients, as determined by the attending physician and nursing staff on a cases {sic} by case basis only after careful assessment of these individual {sic}. The physician must document approval in the medical record for the use of a family//significant other in observation procedures.... RN #6 told the surveyor that they did not see physician approval for the use of family for observation procedures, and was unable to locate documentation of an assessment of family members for purposes of providing observation to the patient.

Patient #17 presented to the ED, accompanied by their therapist, with SI. Patient #17 was initially a voluntary admission, and did not have an ECO. 1:1 sitter was initiated at 12:50 p.m. on 12/6/19 by nursing after the patient was triaged; there was no physician order for 1:1 sitter, and documentation by the sitter stopped at 3:00 p.m..

The record evidenced that on 12/6/19 at 3:47 p.m., Patient #17 walked out of the ED and said they could not be forced to stay. The CSB was contacted, and an ECO was issued. Nursing note at 4:24 p.m. documented that law enforcement was putting Patient #17 on a paperless ECO. At 12:40 p.m. on 12/11/19 RN #6 told the surveyor that The doctor writing an order for 1:1 sitter seems to be the inconsistent part, that seems to be our great opportunity to improve. It's one of the first things we talked about in huddle this morning, closing the loop with initiating 1:1.

Patient #18 presented to the ED due to complaints of a three (3) month history of abdominal pain and nausea and vomiting. A computed tomography (CT) scan was ordered in the ED, and the results were concerning for metastatic cancer. Patient #18 was admitted to the progressive care unit (PCU) at 7:27 p.m. A history and physical (H&P) documented 11/19/19 at 9:33 p.m. by a doctor of osteopathic medicine, first year resident (DO R1), evidenced that Patient #18 expressed suicidal ideations during the intake interview. Suicide precautions and a 1:1 sitter were ordered. The surveyor was given an undated document stamped with Patient #18's name, and included the patient's hospital number, date of birth, admitted , and was titled Suicide Precautions Observation Record. For type of precautions Standard (q15), line of sight, and 1:1 were all checked. The document evidenced the comment suicide precautions initiated, and a time of 10:30 p.m., almost one (1) hour after suicide precautions were ordered by the clinician.

At the top of the document in the key, the document included an environmental checklist which documented that: All linens counted; All patient belongings secured (clothing, jewelry, shoes); Patient is in paper scrubs/gown without ties and footies; Patient had been wanded for any metal/sharps in their possession (on arrival and any time suspicion is aroused); Visitors have had their belongings secured and did not given any items to patient prior to authorization; Bathroom door (if applicable) is locked to prevent unknown patient access; Plastic liners removed from trash cans; All cords not needed for ongoing patient care are removed; All sharps containers are removed; All glove boxes/gloves are removed; All supplies in the room that are sharps/plastics/ligature prone removed or secured; Dietary notified to provide paper plates, plastic utensils, and no knives; Electric beds disabled/unplugged; Nurse call cord secured.

Admission Health History was entered by RN #22 on 11/19/19 at 9:57 p.m. documented valuables were kept by patient, and that a medication reconciliation was done. A nursing note documented by RN #22 on 11/20/19 at 2:30 a.m. evidenced that Patient #18 told the nurse that there was a knife in the pocket of their jeans, in a bag, in the room. RN #22 documented that Security came back for a second time and researched [patient's] belonging {sic} incase {sic} [patient] had other itmes {sic}. Security did take the knife, belt, lighter, screws, charger, keychain and trash bags. Along with other medications that the pt did not disclose during the med rec. Medications were placed in a a bag and will be given to pharmacy.

At 4:00 a.m. on 11/20/19 RN #22 documented in a nursing note the physician was notified that Patient #18 was upset with the 1:1 sitter because items noted above had been taken from the patient and secured. The doctor attempted to explain why the items were removed from the room, and Patient #18 became more upset, self-removed the intravenous (IV) line, telemetry box, and got on the elevator, accompanied by hospital security and the nursing supervisor. The local police department was notified, and the physician called to obtain a TDO. Patient #18 went to the hospital lobby where the local police handcuffed and detained the patient until the TDO was obtained.

Patient #18 was taken back to the PCU and placed in four (4) point restraints.

Staff Member (SM)#15, a security guard, was interviewed on 12/12/19 at 9:50 a.m. to discuss security's role in checking for contraband for patients on suicide risk. SM #15 told the surveyor that security is called when patients in the ED are placed on suicide precautions. The surveyor was told that usually security wands patients with a hand-held metal detector, removes any bags, checks pockets of any clothing, and removes any contraband like knives or other weapons, which are placed in a lock box. Narcotics are sent to the local police department. SM #15 told the surveyor that nursing staff generally remove clothes after security has done their safety check, and that the nursing staff would ensure that clothes, shoes, belts, and other personal belongings are placed in a locker. When the surveyor inquired about inpatients on suicide precautions, SM #15 said Sometimes if it is ordered from the floor, we aren't even notified, most of the time. We only get notified if suicide precautions are started in the ED.

SM #15 returned to the conference room after looking through reports, and told the surveyor that security was called to the floor and searched Patient #18, and provided the surveyor with the following information documented by the security guard on duty 11/20/19:

On 11/20/19 at 2:15 a.m. security received a call from PCU. There was no information given, just a call for my presence in Room 227. Upon arrival, I was informed that the patient [patient hospital #] had a knife in [their] belongings. I searched [patient's] belongings. I removed a mass quantity of medication which was given to the Nurse. I took into my custody, the knife, a belt, lighter, phone charger cord, roll of blue plastic bags, a package of screws, and keys on a retractable chain. I bagged and tagged them and placed them in the security office. Nothing further to report.

At 4:00 a.m. on 11/20/19 the security guard documented that they were called to PCU for Patient #18, who was on suicide precautions and attempting to leave the hospital against medical advice (AMA). Security wrote that after the patient was brought back to the unit to the room by local police officers and the nurse leader, the patient was restrained, and confiscated items mentioned above were returned to the patient's family member.

The facility's policy entitled Suicide Precautions effective, last revised 11/2018, with expiration of 11/2021, was reviewed, and revealed the following information, in part:

Suicide precautions will be initiated when a physician's order has been written on any patient who has made a suicide attempt or is expressing suicidal ideation. Suicide Precautions may be initiated by the charge nurse, manager or clinical coordinator in a crisis situation, until collaboration with the attending physician can occur. The goal is to provide protection for the patient in the least restrictive environment that allows for the necessary level of observation and/or physiologic monitoring. Interventions range from regular and periodic observation to 1:1 contact observation.

Observation will be provided by nursing staff (RN, LPN, NA). Use of family members and/or significant others as observers is determined by the attending physician and nursing staff on a cases {sic} by case basis only after careful assessment of these individual {sic}. The physician must document approval in the medical record for the use of a family//significant other in observation procedures. If the patient is a minor, it is preferred that a family member stay at all times unless observed family dynamics contribute to patient's distress.

The level of precautions needed may be ordered by the attending physician or the nursing staff. Should the nursing staff initiate any level of observation, rationale for this decision is recorded in the medical record and the patient's physician notified as soon as possible. If the physician concurs, an order must be written. Orders for suicide precaution must specify what level of observation is intended. Level of observation can be reduced only by physician order...If the patient is determined to be of suicide risk, the results of this screening will be clearly communicated to the treatment team immediately. a. A YES answer to any of the suicide risk screening questions will identify patients at risk for suicide. Any patient that responds YES will be placed on suicide precautions and the RN will assign patient observation monitoring immediately and a licensed independent practitioner (LIP) order will be generated in order to gain further suicide risk assessment by a QUALIFIED MENTAL HEALTH PROFESSIOANL {sic} (QMHP) or assigned LIP and determine ongoing safety observation and monitoring level. Safe environment and patient safety guidelines will be implemented...6. Patients, who no longer meet guidelines for heightened protective measures or precautions upon reassessment, will be evaluated for a decrease in protective measures or precautions by a physician who will provide appropriate orders....

The policy's guidelines for monitoring and observation of patients for Standard Observation included to monitor and observe a minimum of every 15 minutes and/or place a trusted family member, friend, or significant other with the patient. Per the policy, Standard Observation may be used for patients who have not had a suicide attempt within the previous year, have not displayed self injurious behaviors in the preceding eight (8) to twelve (12) hours, is having SI, with no plan for self-harm.

The policy defined Line of Sight Observation as continuous visual observations, to be used for extremely confused patients at risk of unintended self-harm, medically unstable patients, and patients after a suicide attempt, patients with SI, patients at risk of having assaultive behavior, but who do not meet 1:1 guidelines. Patients on line of sight observation, per the policy, are not to be out of the visual contact of a staff member at any time.

The policy defined 1:1 monitoring and observation as the patient is NEVER to be out of arms reach of the assigned and dedicated staff member, and used for patients who have attempted suicide within 48 hours, displayed self-injurious behaviors within 8-12 hours, current SI with plan, having command hallucinations to harm self, feelings of hopelessness, have experienced traumatic loss, event or disruption within 24 hours.

On 12/12/19 between 9:30 a.m. and 10:30 a.m. the surveyor discussed serious concerns related to implementation of the facility's suicide precaution policy with Staff Members # 4, 6, 13, 15, and 16. The discussion included, but was not limited to, the facility staff's failure to remove contraband, which included among other items, a knife, belt, plastic trash bags, cell phone cord, and mass quantities of unknown medications, from Patient #18, who was on suicide precautions.

Show Text of Violation

Based on observation and interview, the facility failed to maintain the automatic sprinkler system.

The findings include:

On 06/28/2017 at 02:06 pm, it was observed that there was a sprinkler escutcheon missing in ER medical director area.

On 06/28/2017 at 10:00 am, it was observed that there was a loaded sprinkler head on the second floor soiled linen room.

On 06/28/2017 at 10:05 am, it was observed that there was a loaded sprinkler head near the window of the second floor break room.

On 06/28/2017 at 10:09 am, it was observed that there was a loaded sprinkler head in the second floor waiting room.

On 06/28/2017 at 10:21 am, it was observed that there was a loaded sprinkler head in the second floor Cardio Director's office.

On 06/28/2017 at 10:22 am, it was observed that there was a loaded sprinkler head in second floor room 2-27.

On 06/28/2017 at 10:25 am, it was observed that there was a ceiling tile missing in the second floor janitor's closet.

On 06/28/2017 at 10:31 am, it was observed that there was a loaded sprinkler head in room 2-01 on the second floor.

On 06/28/2017 at 11:02 am, it was observed that there was a loaded sprinkler head in the ICU locker room on the second floor.

On 06/28/2017 at 11:33 am, it was observed that there was a loaded sprinkler head in room 2-13 on the second floor.

On 06/28/2017 at 11:35 am, it was observed that there was loaded sprinkler heads in rooms 2-19 and 2-21 on the second floor.

On 06/28/2017 at 11:48 am, it was observed that there was loaded sprinkler heads in room 2-24 on the second floor.

On 06/28/2017 at 01:50 pm, it was observed that there are combustible materials stored within 18 inches of sprinkler head deflector in the volunteers storage room on the third floor.

On 06/28/2017 at 01:55 pm, it was observed that the sprinkler head in bulk IV storage room on the third floor, is recessed too far within the escutcheon which does not allow proper coverage of room.

On 06/28/2017 at 01:56 pm, it was observed that the sprinkler head in the compounding area, of the pharmacy on the third floor, is not oriented parallel to the ceiling and a surface mounted light fixture obstructs the sprinkler head.

On 06/28/2017 at 02:35 pm, it was observed that there was a loaded sprinkler head in room 3-05 on the third floor.

On 06/28/2017 at 02:40 pm, it was observed that there was a loaded sprinkler head in room 3-30 on the third floor.

On 06/28/2017 between 10:00 am and 04:00 pm, it was observed that electrical wires were found in contact with sprinkler piping in several areas throughout the building.

On 06/28/2017 at 09:48 am, it was observed that there was combustible storage within 18 inches of the bottom of sprinkler head deflectors in the EVS break room.

On 06/28/2017 at 10:47 am, it was observed that there were ceiling tiles missing in the old HIM office by human resources.

On 06/28/2017 at 11:05 am, it was observed that there was a sprinkler head escutcheon missing in the chapel.

On 06/28/2017 at 11:24 am, there are ceiling tiles missing throughout the building in various areas.

On 06/28/2017 at 11:38 am, it was observed that sprinkler heads are recessed into the ceiling at DI in the women's dressing room.

On 06/28/2017 at 11:58 am, it was observed that sprinkler heads are recessed into the ceiling in the OR Suite closet, behind the autoclave.

On 06/28/2017 at 12:02 pm, it was observed that sprinkler heads are recessed into the ceiling in the OR Suite Managers Office.

On 06/28/2017 at 12:09 pm, it was observed that there is a sprinkler head escutcheon missing in room 8 of the OR Suite.

The Maintenance Director acknowledged the above findings.

Show Text of Violation

Based on observations and interview, the facility failed to maintain smoke barriers.

The findings include:

On 06/28/2017 at 02:23 pm, penetrations were observed and fire stopping not provided for rated wall assembly penetrations in the emergency prep room.

On 06/28/2017 at 02:23 pm, penetrations were observed and fire stopping not provided above the ceiling in the second floor janitors closet.

On 06/28/2017 at 03:20 pm, penetrations were observed and fire stopping not provided in the first floor dining room, rated wall assembly has MC cable above ceiling penetration that is not being sealed.

On 06/28/2017 at 03:28 pm, penetrations were observed and fire stopping not provided in first floor dietary director's office,above ceiling that is not fully sealed.

On 06/28/2017 at 02:00 pm, penetrations were observed and fire stopping not provided around the conduit penetrations of the communications room on the second floor.

On 06/28/2017 at 02:30 pm, penetrations were observed and fire stopping not provided at the 4 inch sprinkler piping above the ceiling of the men's first floor bathroom. Penetrations were observed and fire stopping not provided at the lobby and at the bottom of the stair to the first floor lobby.

On 06/28/2017 between 03:00 pm and 04:30 pm, penetrations were observed and fire stopping not provided for several holes penetrating the half hour smoke barrier wall above the ceiling at HIM, AED outside of the cafeteria. An approximate two foot section of wall had been removed above the cafeteria double doors from the corridor.

On 06/28/2017 at 10:08 pm, penetrations were observed and fire stopping not provided above the ceiling in the OB clean utility / kitchen IT closet.

On 06/28/2017 at 03:25 pm, penetrations were observed and fire stopping not provided on the first floor above the ceiling at the security office door.

On 06/28/2017 at 03:43 pm, penetrations were observed and fire stopping not provided on the first floor in the corridor outside the door and above the ceiling at the doctor's workspace beside the security office.

On 06/28/2017 at 03:45 pm, penetrations were observed and fire stopping not provided on the first floor above the ceiling in the doctor's workspace in the one hour separation wall.

On 06/28/2017 at 03:52 pm, penetrations were observed and fire stopping not provided on the first floor above the ceiling at the rear wall in room 14 in ER.

On 06/28/2017 at 03:59 pm, penetrations were observed and fire stopping not provided on the first floor above the ceiling at the rear wall in room 10, where conduit penetrates the rear wall in ER.

On 06/28/2017 at 04:02 pm, penetrations were observed and fire stopping not provided on the first floor above the ceiling at the rear wall in room 9 in ER.

On 06/28/2017 at 04:19 pm, penetrations were observed and fire stopping not provided on the first floor above the ceiling in the doctor's lounge.

The Maintenance Director acknowledged the above findings.

Show Text of Violation

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure the facility policy regarding complaints and grievances was followed for one (1) of thirty-three (33) patients of the survey sample, Patient #15.

Patient #15 made a verbal complaint regarding treatment, which, though reported, was not followed through per the facility policy and procedure for complaints and grievances.

The findings included:

Review of the clinical record for Patient #15 revealed a Patient Notes entry dated 6/12/17 at 0200 (2:00 a.m.) which evidenced: (sic) Patient accused of (sic) Nurse harming patient during care after incontinent episode. Nurse attempted (sic) patient is fine and clean after care. Patient called 911 and family report of (his/her) concerns. Nurse attempted again to explain patients (spouse) is ok and clean after nurse care. (Name of RN) Charge Nurse aware, Security/Police arrived charge nurse explain events lead up to patient calling (sic). (Name of RN) House Supervisor notified by (name of RN) Charge Nurse. Call bell in reach. Sitter in room. Nurse ask patient if anything to do to assist or help patient stated no. Patient stated feels nausea nurse offered call MD for nausea medication the patient declined stated don't trust you people (sic). Nurse offer ginger ale help decrease nausea patient accepted.

On 6/14/17 at 9:40 a.m. the surveyor requested to review the facility's follow up concerning the allegation.

On 6/14/17 at 12:15 p.m., Staff Member #21 presented the surveyor with a report dated 6/14/17 and stated, They reported the concern to the clinical coordinator and supervisor and the issue had been resolved in their mind, but they forgot to document it all. We will re-educate them regarding the proper procedure.

The report document included the following information, in part: 6/14/17 1124 (11:24 a.m.) The events were reported to myself and (name) by (name) on 6/12/17 at 0800 (8:00 a.m.)...on the night of 6/12/17 around 0200, the (spouse) was incontinent of urine with nursing staff present in room to assist patient with personal care. The (spouse in bed (number) complained that the staff was being mean to (spouse) and abusive. (Name of RN) explained to the patient that they were assisting the patient in (bed number) to be cleaned up with linens changed. (Spouse) proceeded to call 911 to report the abuse to the police, then (he/she) complained of nausea to the nurse ...upon getting ready to leave the room after making sure both patients were taken care of, (name) walked out to find the police along with security standing in the hallway...(name/supervisor) was made aware of the situation by (name) that night. Staff Member #21 stated, they reported the issue and there was the nurses note made but there should have been a documentation regarding the occurrence for us to review...

The facility policy and Procedure Patient Complaints/Grievances: Management and Resolution was reviewed and evidenced, in part: ...Verbal Complaint is a grievance if it cannot be resolved at the time of the complaint by the staff present...3. All complaints should be documented, whether resolved or not, in the Notification system via (name of computer program)...

Show Text of Violation

Based on interviews and document review, it was determined the facility staff failed to ensure timely documentation of restraint monitoring for 3 of 3 patients sampled for restraint review (Patient #5, Patient #8, and Patient #27).

The findings include:

Review of the clinical documentation of the three (3) patients sample for restraint review (Patient #5, Patient #8, and Patient #27) revealed that patient safety and dignity checks were not being documented at the time the checks were reported to have been performed instead the safety and dignity checks were being documented as a summary note every two (2) hours and/or at the end of the shift. According to the facility policy and procedure safety and dignity checks are to occur at least three times an hour.

The following information was found in a facility policy and procedure entitled 'Patient Restraint / Seclusion' (this policy and procedure had a last revised date of 06/2017): A trained staff member monitors each patient in restraint [sic] or seclusion at least three (3) times an hour for safety and to confirm that the patients [sic] rights and dignity are maintained. This check will be documented in either electronic record or on paper and may be recorded at the end of the shift. If a paper checklist is used as a summary, recording time and observation form each of the three (3) times an hour check, may be recorded at the end of the shift and the checklist scanned into the EHR/HPF patient record. [sic]

The three aforementioned patients' restraint documentation were reviewed with Staff Member (SM #3) (the facility's Quality Director) on 6/13/17 and/or SM #21 (the facility's Risk Manager) on 6/14/17. The failure to see documentation of the safety and dignity checks at the time the checks were performed was discussed with both staff members.

During an interview on 6/15/17 at 8:35AM, the facility's Quality Director (SM #3) reported the three (3) times an hour safety and dignity checks needs to be documented at the time the checks were completed not as a summary at a later time. SM #3 reported a paper form was being implemented to capture this documentation and the paper forms would be scanned into patients' clinical documentation when completed; SM #3 provided the survey team with a blank copy of this paper form.

Show Text of Violation

Based on interviews and documents review, it was determined the facility staff failed to ensure a patient having restraints in use was evaluated, within the required time limits, by a licensed independent practitioner (LIP) for 1 of 3 patients sampled for restraint use (Patient #5).

The findings include:

Patient #5 did not have an assessment documented by a LIP within the first hour after physical and chemical restraints were initiated due to violent behaviors.

Patient #5's clinical record included the following orders:

- Haldol 2mg IV (intravenously) one time on 2/23/17 at 6:01AM, and

- Soft restraints all extremities with the criteria for release being documented as when the patient stops being combative; this order was documented on 2/23/17 at 6:04AM.

The following nurse's note was documented on 2/23/17 at 6:22AM: (patient) noted to be attempting to hit and kick staff, yelling out. [sic] and pylling [sic] off bipap mask; unable to keep (oxygen) on patient; (oxygen saturation) 78% with mask off and no (oxygen) on; order received and (patient) placed in 4 point soft restraints for (his/her) safety and staff safety and to be able to adequately oxygenation (patient); after restraints applied, (nasal cannula) placed on (patient) and (oxygen saturation) still 84 -85%; haldol ordered and administered and bipap placed on (patient) ... The physical restraints were documented as being discontinued on 2/23/17 at 6:54AM.

An LIP assessment was not completed until 2/23/17 at 9:49AM; this was greater than one (1) hour after the physical and chemical restraints were initiated. The absence of an LIP assessment within the first hour after restraints were used for violent behaviors was discussed with Staff Member (SM) #3 (the Quality Director) on the morning of 6/13/17. SM #3 stated the residents (physicians) are usually in the ICU between 5AM and 7AM; SM #3 reported that Patient #5 was in the ICU when the restraint order was given at 6:04AM. The first documentation by a LIP after the aforementioned restraint use was documented as occurring on 2/23/17 at 9:49AM; no earlier LIP assessment was found by or provided to the surveyor.

Show Text of Violation

Based on interview, medical record review and document review, the facility staff failed to ensure vital signs (VS) were obtained and documented per the facility policy/procedure for 2 of 3 patients reviewed regarding the administration of blood products, Patients #2 and #4.

Findings include:

The facility policy and procedure titled Blood and Blood Product Administration included the following information under Procedure General Guidelines: ...18. Vital signs (TPR, BP) will be checked prior to initiating the transfusion, fifteen minutes after transfusion initiation, and every hour during the transfusion....

A review of Patient #2's medical record revealed an order written 6/8/17 for the transfusion of two units of FFP (fresh frozen plasma). Nursing documentation in the record was that the first unit of FFP was administered between 7:58 AM and 8:30 AM, with VS documented at 7:58 AM. VS were not documented 15 minutes after the initiation of the first unit of FFP, or after the first hour. VS were recorded next at 10:02 AM.

The second unit of FFP was documented as administered between 9:57 AM and 11:00 AM. VS were documented at 10:02, but did not include documentation of the temperature. There were no VS documented 15 minutes after initiation, or after one hour. VS were recorded next at 1:57 PM.

A review of Patient #4's medical record revealed an order for two units of FFP written on 6/6/17. Documentation was that the first unit was administered between 11:29 AM and 11:51 AM. VS were obtained and documented at 11:10 AM, prior to the initiation of the first unit; there were no VS documented 15 minutes after FFP was started, or after the infusion was completed. At 11:54, there was a nursing note that stated first unit FFP hung with no reaction, they will start second bag in the OR (operating room).

The concerns were discussed with Staff Members #6, 23, and 33 on 6/13/17 at approximately 1:30 PM. Staff Member #23 searched the record for VS documentation unsuccessfully, and stated there are no other VS documented with the FFP administration for either patient.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and document review, it was determined the facility staff failed to ensure clinical documentation contained information addressing the implementation of physician orders for 1 of 33 sampled patients (Patient #8). Facility staff also failed to ensure the response to medication was documented for 2 of 2 patients, (Patient #15 and Patient #1) who were administered an anti-anxiety agent.

The findings include:

1. Review of Patient #8's clinical documentation indicated the facility staff failed to implement physician orders for CIWA (Clinical Institute Withdrawal Assessment) including not completing CIWA assessments as ordered and not administering CIWA medications as ordered.

Patient #8's clinical documentation included orders for CIWA assessment dated [DATE] at 6:17PM. Patient #8's clinical documentation was reviewed on 6/13/17 and 6/14/17 with the facility's Quality Director (Staff Member (SM) #3).

On 6/14/17 at 9:25AM, SM #3 was asked how soon the first CIWA assessment should be completed. SM #3 stated the first assessment of the CIWA should occur within 1 - 2 hours of the order being given. The following CIWA documentation as found in Patient #8's clinical documentation:

- The first assessment was completed on 5/21/17 at 9:31PM with a score of 9; this was greater than 3 hours after the order was given. Medication orders indicated that for a CIWA score of 8 - 15 that Ativan 1mg should be administered by intramuscular (IM) injection. Patient #8's scheduled Ativan was administered by mouth but the IM injection was not addressed. SM #3 stated the physician should have been contacted for guidance on the Ativan 1mg injection order. The CIWA assessment orders indicated if an assessment score was 8 - 15 then the CIWA needed to be repeated (e)very 2 hours for 24 hours then every 4 hours while awake.

- The second CIWA assessment was completed on 5/22/17 at 4:31AM; this was greater than 2 hours from the previous CIWA assessment. The second CIWA assessment score was an 8. Based on the physician orders Patient #8 should have been administered Ativan 1mg IM injection; no Ativan was documented as being administered.

- The third CIWA assessment was completed on 5/22/17 at 8:16AM; this was completed according to the time limit required by the orders. The third CIWA assessment was scored as a 12. Based on the physician orders Patient #8 should have been administered Ativan 1mg IM injection; no Ativan was documented as being administered. The CIWA assessment orders indicated if an assessment score was 8 - 15 then the CIWA needed to be repeated (e)very 2 hours for 24 hours then every 4 hours while awake.

- The forth CIWA assessment was completed on 5/23/17 at 1:26AM; this was greater than 2 hours from the previous CIWA assessment. The forth CIWA score was 4. No medication was required based on this score. The CIWA assessment orders indicated if an assessment score was less than 8 then repeat the CIWA assessment (e)very 4 hours for 24 hours then every 4 hours while awake.

- The fifth CIWA assessment was completed on 5/23/17 at 8:20AM; this was greater than 4 hours from the previous CIWA assessment. The fifth CIWA score was 1. No medication was required based on this score. The CIWA assessment orders indicated if an assessment score was less than 8 then repeat the CIWA assessment (e)very 4 hours for 24 hours then every 4 hours while awake.

- The sixth CIWA assessment was completed on 5/23/17 at 11:10AM; this was completed according to the time limit required by the orders. The sixth CIWA assessment was scored as a 14. Medication orders indicated that for a CIWA score of 8 - 15 that Ativan 1mg should be administered by intramuscular (IM) injection. Based on the physician orders Patient #8 should have been administered Ativan 1mg IM injection but Ativan 2mg IM injection was documented as being administered. The CIWA assessment orders indicated if an assessment score was 8 - 15 then the CIWA needed to be repeated (e)very 2 hours for 24 hours then every 4 hours while awake.

- The seventh CIWA assessment was completed on 5/23/17 at 4:38PM; this was greater than 2 hours from the previous CIWA assessment. The seventh CIWA assessment was scored as a 33. Documentation indicated a physician was notified of the change in the patient's condition at 4:45PM. The physician ordered Versed 2mg IV (intravenously) and 4 point soft restraints.

The aforementioned documentation was reviewed and confirmed with SM #3 on 6/14/17 at 9:25AM.

2. Patient #15 was admitted to the facility on [DATE] with diagnoses that included [DIAGNOSES REDACTED]](irregular heart rhythm) with RVR (rapid ventricular rate), and congestive heart failure.

Review of the clinical record documented Patient #15 received Ativan (Lorazepam- an antianxiety medication) IV (intravenous) on 6/12/17 at 3:31 a.m. The order was written: Ativan 1mg (one milligram) once IV (intravenous) for agitation or anxiety. There was no documentation in the clinical record as to the reason the medication was administered, and no follow-up documentation as to the effectiveness of the medication once administered.

On 6/12/17 at 22:39 (10:39 p.m.) it was documented the nurse called the physician and again received an order for Ativan 0.5 mg once IV, however there was no documentation in the clinical record as to why the patient required the medication and no documentation of follow-up as to the effectiveness once administered.

On 6/14/17 at 00:30 (12:30 a.m.) the nurse again called the physician and obtained an order for Ativan 0.5 mg IV once for Patient #15. There was no documentation in the clinical record as to the reason the patient required the medication and no documentation as to the follow-up effectiveness once the medication was administered.

On 6/14/17 at 11:20 a.m., the surveyor interviewed Staff Member # 30 regarding the documentation of the Ativan. Staff Member #30 stated, There should be some documentation in the nurses notes as to why they called the physician for the order and there should be documentation of the effectiveness...the nurse should go back and reassess the patient and document something in the notes. There is follow-up documentation on pain medications but not anxiety meds...

The concerns were discussed with facility Administration on 6/15/17 at 10:40 a.m

3. A review of Patient #1's record revealed PRN (as needed) orders for the administration of IV (intravenous) Ativan. Documentation in the record was that Patient #1 received 1 mg (milligram) of IV Ativan on 6/10/17 at 7:37 PM; on 6/11/17 at 11:14 AM, 5:39 PM, and 10:32 PM. On 6/13/17 Patient #1 was administered 2 mg of Ativan at 11:09 AM. A post assessment response to the administration of the Ativan was not documented in the record.

On 6/14/17 at 9:55 AM, Staff Member #23 was interviewed about documentation of response to the PRN administration of Ativan, and he/she stated There are no post assessments for PRN Ativan. That is attached for narcotic/pain medication administration, but it's not there for the Ativan.

Show Text of Violation

Based on observations and staff interview, the facility staff failed to ensure that point of care equipment used for more than one patient was cleaned per facility policy, in a manner to prevent transmission of communicable disease, and that the physical environment was sanitary.

Findings include:

While touring the ED (emergency department) on 6/13/17, the surveyor observed the following in the laboratory space adjacent to the triage area:

At 10:30 AM, the surveyor observed equipment used for point of care testing sitting in the charging dock, labeled #3. The equipment had a used cartridge containing blood inserted into the hand-held monitor. There was also dried blood on the side of the equipment. Staff Member #31, who was accompanying the surveyor on the ED tour, stated the cartridge should have been thrown away, and the I-Stat should be cleaned after use, that blood shouldn't be there. The sharps container sitting in the laboratory had a white latch on it which contained what appeared to be dried blood splatter. Staff Member #31 stated you're right, that is blood.

On 6/15/17 at 11:00 AM, the surveyor, accompanied by Staff Member #6, observed glucose monitoring on the PCU (progressive care unit). Staff Member #32 gathered the necessary supplies and went into room #204. Staff Member #32 placed a black plastic box containing supplies on a chair, then laid the glucometer on the bed. After obtaining the blood sample and recording the BS (blood sugar) result, Staff Member #32 cleaned the glucometer with sanitizing wipes, picked up the black box, which he/she did not sanitize, placed the clean glucometer on top of the box, and went to room #207 to obtain the next BS.

Staff Member #32 placed the black supply box on a chair, laid the glucometer on the patient's bed, and obtained and ran the test. After removing his/her gloves, Staff Member #32 picked up the black box, and carried the glucometer out of the room and proceeded to room #210. Staff Member #32 did not clean the glucometer or the black box. Staff Member #32 placed the black box on top of the dirty laundry container in room #210, placed the glucometer on the bed, and obtained the patient's BS. After he/she finished, Staff Member #32 cleaned the glucometer, and picked up the black box.

The surveyor discussed the observations that the glucometer was not sanitized between the second and third patient, and the failure to sanitize the black box containing supplies with Staff Member #6, who said yes, I noticed (Staff Member #32's name) did not clean the glucometer before going to room #210, I don't think there were any wipes in that room.

Staff Member #6 and the surveyor talked with Staff Member #32 about not cleaning the glucometer before exiting room #207 and going to room #210, and he/she stated there weren't any wipes in the room to use.

The facility's policy and procedure titled POC Nova Glucose Meter Procedure was reviewed.

Staff Member #3 advised the surveyor on 6/14/17 at approximately 3:00 PM that the policy was for all POC (point of care) equipment, and not strictly for glucometers. Under the heading Equipment and Materials, the section Meter Cleaning included the following information: Meters must be cleaned after each patient test. Clean the meter with a cloth that has been dampened with a 10% bleach solution or disinfectant wipe. Immediately follow with a water dampened cloth to remove all cleaning residue. Dry thoroughly with a soft cloth or lint-free tissue.

Staff Member #31 was aware of the concerns at the time of discovery, and responded as noted above.

Show Text of Violation

Based on interviews and document reviews, it was determined the facility staff failed to ensure a patient representative's grievance was addressed via the facility's grievance process.

The findings include:

Review of the facility's policy and procedure entitled, Patient Complaints / Grievances: Management And [sic] Resolution revealed the following information:

- To assure that patient and family complaints / grievances are addressed in a timely, reasonable, and consistent manner. (Hospital name omitted) maintains a mechanism for receiving, investigating, and responding to grievances regarding the quality of care or patient rights.

- Complaint is a concern represented by a patient or patient's representative that can be addressed or resolved promptly by staff members who are present at the time of the complaint...

- Patient Grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint) by a patient, or the patient's representative, regarding the patient's care...

- Verbal Complaint is a grievance if it cannot be resolved at the time of the complaint by the staff present, if it is postponed for later resolution, if it is referred to other staff for later resolution, if it requires investigation, and/or if it requires further actions for resolution.

- All complaints should be documented, whether resolved or not, in the Notification system via (name of computer system).

- If the complaint is unresolved, it is routed to the appropriate responsible individual, i.e. immediate supervisor, Clinical Coordinator or Department Director. A notification is initiated in (name of computer system) and the Patient Grievance process is followed.

- Written follow up to the patient and/or responsible party, will be completed within 7 working days of receipt of the grievance...

The following information, documented by a nurse, was found in Patient #5's clinical record (dated as having occurred on 1/11/15 at 12:30PM): ... SPOKE WITH (ADULT CHILD) AND SITTER WHERE THEY BEGAN TO TELL ME ABOUT THE CARE THEY HAVE RECEIVED HERE AND THERE [sic] EXTREME DISPLEASURE IN IT. I HAVE LISTENED TO THEIR STORY AND HAVE RECOMMMENDED [sic] THEY SPEAK WITH THE DIRECTOR OF THIS FLOOR AND OR THE CNO OF THE HOSPITAL. I HAVE GIVEN THE NUMBERS OF (hospital employee names omitted).

The survey team was provided with a grievance list which would have include the time period of the aforementioned documentation found in Patient #5's clinical record; the documented family concerns related to Patient #5's care was not included on the grievance list provided to the survey team.

On 4/17/15 at 10:50AM the a facility's quality staff member (Employee #3) was asked if the aforementioned documented Patient #5's family's concerns were made into an official grievance; Employee #3 reported that the concerns had not been entered into the facility grievance records, an investigation had not been completed, and a letter related to an investigation had not been sent to the complainant.

Show Text of Violation

Based on interviews and record reviews, it was determined that clinical documentation failed to include a current physician order addressing code status 1 of 6 sampled patients (Patient #5) whose advanced directives were reviewed.

The findings include:

Review of Patient #5's clinical record failed to reveal evidence of a physician order for DNR (Do Not Resuscitate) and failed to reveal evidence of a discussion with the patient's family regarding the patient's DNR status.

Patient #5's clinical record contained a VIRGINIA EMERGENCY MEDICAL SERVICES DO NOT RESUSCITATE ORDER dated 8/27/03; under the date the following was written in parentheses: Expires one year from this date.

Patient #5's clinical record also contained an ADVANCE MEDICAL DIRECTIVE document, dated August 9, 2000, which addressed the patient's medical wishes and appointment of an agent to make health care decisions for the patient.

The following documentation was found in Patient #5's clinical record dated 1/12/15 at 9:47AM: PATIENT ASSESSED NO HEART TONES OR LUNG SOUNDS UPON AUSCULTATION PER 2 RNS (registered nurses). MD (medical doctor) NOTIFIED TOD (time of death)-0905.

Review of the facility policy entitled, Withholding and Withdrawing Life Sustaining Treatment revealed the following information: The patient's medical record must contain the following documentation: A. Orders 1. A formal order written in the medical record is necessary in any situation in which therapy is to be limited. The order shall include the specific procedure / treatment which is to [sic] withheld or withdrawn and under what circumstances this is to be done; and any modification which are specific to the individual patient situation, in accordance with the patient's wishes. ... 3. If the patient is discharged the order is automatically canceled and, upon readmission a new order would need to be written if indicated and desired by the patient or surrogate.

During an interview with Employee #2 (a facility quality staff member) on 4/16/15 at 2:55PM; Employee #2 reported he/she did not find a physician order for Do Not Resuscitate/Do No Intubate in Patient #5's clinical record.

Show Text of Violation

Based on interviews and document reviews, it was determined that care plans related to restraint use were not complete for 4 of 4 patients sampled for restraint review (Patient #1, Patient #2, Patient #3, and Patient #4).

The findings include:

Review of Patient #1's, Patient #2's, Patient #3's, and Patient #4's restraint care plans failed to identify interventions addressing safety / dignity checks.

Review of the facility policy and procedure entitled, Patient Restraint / Seclusion, included the following information:

- A trained staff member monitors each patient in restraints or seclusion at least 3 times an hour for safety, and to confirm that the patients [sic] rights and dignity are maintained. This check will be documented in either electronic record or on paper and may be recorded at the end of the shift. If a paper checklist is used, it is to be maintained as a part of the permanent medical record.

- Care of the Patient / Plan of Care: a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications.

Patient #1's care plan for restraints identified the 'problem' as 'Restraints' with an 'outcome' of 'Restraint free and without injury Patient will meet the criteria for release of restraints and will be free of injury related to the restraint episode'. This care plan was created on 8/23/14 at 3:00PM. No interventions were found to be care planned related to the restraints.

Patient #2's care plan for restraints identified the 'problem' as 'Restraints' with an 'outcome' of 'Restraint free and without injury Patient will meet the criteria for release of restraints and will be free of injury related to the restraint episode'. This care plan was created on 11/16/14 at 5:29PM; no interventions were found to be care planned related to the restraints. On 11/16 at 10:31PM a 'Restraint Evaluation / 2nd Tier Review' documentation added the intervention of an every two hour nursing assessment.

Patient #3's care plan for restraints identified the 'problem' as 'Restraints' with an 'outcome' of 'Restraint free and without injury Patient will meet the criteria for release of restraints and will be free of injury related to the restraint episode'. This care plan was created on 11/6/14 at 2:04PM. No interventions were found to be care planned related to the restraints.

Patient #4's care plan for restraints identified the 'problem' as 'Restraints' with an 'outcome' of 'Restraint free and without injury Patient will meet the criteria for release of restraints and will be free of injury related to the restraint episode'. This care plan was created on 2/17/15 at 10:10AM. No interventions were found to be care planned related to the restraints.

Show Text of Violation

Based on interviews and record reviews, it is determined the facility staff failed to ensure patient restraints were used according to facility policy for 3 of 4 patients sampled for review of restraint use (Patient #1, Patient #3, and Patient #4).

The findings include:

1. The facility staff failed to document the following for Patient #3: (a) dignity / safety checks, (b) who specifically was notified of the patient being placed in restraints, and (c) what information was provided to the patient's family at the time of notification of restraint use.

Review of the facility policy and procedure entitled, Patient Restraint / Seclusion, included the following information:

- A trained staff member monitors each patient in restraints or seclusion at least 3 times an hour for safety, and to confirm that the patients [sic] rights and dignity are maintained. This check will be documented in either electronic record or on paper and may be recorded at the end of the shift. If a paper checklist is used, it is to be maintained as a part of the permanent medical record.

- The patients [sic] family is informed of restraint use, the purpose of the restraint and the criteria for removal.

Review of Patient #3's clinical record failed to reveal documented evidence of restraint dignity / safety checks. During an interview with Employee #2 (a quality staff member) while reviewing Patient #3's clinical record on 4/15/15 at 10:49AM, Employee #2 reported that he/she could not find the aforementioned dignity / safety checks. (The surveyor was informed that the dignity / safety checks were completed on paper and would had to have been scanned into the electronic clinical record.)

Patient #3's clinical record included information documented on 11/6/14 at 7:34AM indicating the patient had bilateral soft upper extremity restraints applied. The 'Type of restraint' was documented as 'Non-violent'. Documentation indicated that a staff member 'Reviewed reason for restraints with - Family' and 'Reviewed criteria for release with - Family'; the documentation did not specify who was notified.

2. The facility staff failed to document the following for Patient #4: (a) dignity / safety checks and (b) who specifically was attempted to be notified of the patient being placed in restraints.

Review of the facility policy and procedure entitled, Patient Restraint / Seclusion, included the following information:

- A trained staff member monitors each patient in restraints or seclusion at least 3 times an hour for safety, and to confirm that the patients [sic] rights and dignity are maintained. This check will be documented in either electronic record or on paper and may be recorded at the end of the shift. If a paper checklist is used, it is to be maintained as a part of the permanent medical record.

- The patients [sic] family is informed of restraint use, the purpose of the restraint and the criteria for removal.

Review of Patient #4's clinical record failed to reveal documented evidence of restraint dignity / safety checks. During an interview with Employee #2 (a quality staff member) on 4/17/15 at 11:12AM, Employee #2 reported that Patient #4's restraint dignity / safety checks were not found.

Patient #4's clinical record included information documented on 2/17/15 at 3:00PM indicating the patient had bilateral soft upper extremity restraints applied. The 'Type of restraint' was documented as 'Non-violent'. Documentation indicated that Patient #4's responsible party was 'unable to reach' to be notified of the application of restraints; the documentation did not specify who the facility staff attempted to contact.

3. The facility staff failed to document who specifically was notified of Patient #1 being placed in restraints and the facility staff failed to document what information was provided Patient #1's family related to the restraint use.

Review of the facility policy and procedure entitled, Patient Restraint / Seclusion, included the following information: The patients [sic] family is informed of restraint use, the purpose of the restraint and the criteria for removal.

Patient #1's clinical record included information documented on 9/23/14 at 7:55AM indicating the patient had bilateral soft upper extremity restraints applied. The 'Type of restraint' was documented as 'Violent / Self Destructive'. Documentation indicated that 'Restraint Notification to - Family / Guardian'; the documentation did not specify who was notified and what restraint information was provided.

Show Text of Violation

Based on interviews and document reviews, it was determined the facility staff failed to ensure physician orders for restraints for violent or self destructive behavior were renewed within the required time frame for 2 of 4 patients sampled for restraint use (Patient #1 and Patient #3).

The findings include:

1. Patient #1's restraint orders were not renewed within the required time limits.

Review of the facility policy and procedure entitled, Patient Restraint / Seclusion, included the following information: Order for Restraint with Violent or Self Destructive Behavior 1. Physician orders for restraint or seclusion must be time limited, and must specify clinical justification for the restraint / seclusion, the date and time ordered, duration of restraint / seclusion use, the type of restraint, and behavior-based criteria for release. Orders for restraint or seclusion must not exceed: 1. 4 hours for adults, aged 18 years and older ...

Patient #1's clinical record included an order for restraints written on 8/23/14 at 7:55AM; this order was written for non-violent / non-self destructive purposes.

Patient #1's clinical record included an order for restraints written on 8/23/14 at 3:00PM; this order included the following information: Clinical justification of restraint was documented as Physical aggression Locking synthetic leather [sic].

The two aforementioned orders were the only restraint orders found in Patient #1's clinical record. Patient #1's medical record provided evidence the patient was restrained until 8/24/14 at 10:00AM. This would have required a physician to renew the order to address the continuation of the restraint for violent / self destructive reasons at a minimum of every four (4) hours.

The failure of the facility staff to ensure Patient #1's restraint orders were renewed as required was discussed for a final time during a survey team meeting with the facility's CNO, CEO, CFO, COO, and two quality staff members on 4/17/15 at 12:00NOON; no additional information related to this issue was provided to the survey team.

2. Patient #3's restraint orders were not renewed within the required time limits.

During the review of Patient #3's clinical record on 4/15/15 at 10:49AM, with Employee #2 (a facility quality staff member), Patient #3 was found to have three (3) orders for restraints:

- On 11/6/14 at 5:55AM, Patient #3 had an order for soft bilateral upper extremity restraints. The 'Type of restraint' was documented as 'Non-Violent'; but the 'Clinical justification of restraint' included 'Danger to self/others'.

- On 11/6/14 at 8:17PM, Patient #3 had an order for Leather X's 4 (four point leather restraints). The Type of restraint' was documented as 'Violent / Self Destructive' and the 'Clinical justification of restraint' included 'Violent'.

- On 11/7/14 at 12:35AM, Patient #3 had an order for Leather X's 4 (four point leather restraints). The Type of restraint' was documented as 'Violent / Self Destructive' and the 'Clinical justification of restraint' included 'Danger to self/others'.

The following nursing note was documented on 11/6/14 at 3:16PM: 1300-LATE ENTRY: PT BECAME EXTREMELY AGITATED AND COMBATIVE: TORE OUT IV; TOOK LEADS OFF AND PROCEDED TO GET DRESSED TO LEAVE. CODE STRONG WAS CALLED AND ATTEMPTS WERE MADE TO CALM PT. PT BECAME INCREASINGLY DISTRESSED, ANGRY, AND COMBATIVE; PT WAS RESTRAINED. 20MG [sic] ATIVAN (this was later edited to read as 20 mg haldol) IV GIVEN WITH MEDICAL TDO ORDERED. PT CURRENTLY IN 4 PT (point) LEATHER RESTRAINTS.

Review of the facility policy and procedure entitled, Patient Restraint / Seclusion, included the following information:

- An order for restraint or seclusion must be obtained from an LIP / physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release.

- Order for Restraint with Violent or Self Destructive Behavior 1. Physician orders for restraint or seclusion must be time limited, and must specify clinical justification for the restraint / seclusion, the date and time ordered, duration of restraint / seclusion use, the type of restraint, and behavior-based criteria for release. Orders for restraint or seclusion must not exceed: 1. 4 hours for adults, aged 18 years and older ...

Review of Patient #3's clinical record indicated on 11/6/14 at 1:00PM, four (4) point leather restraints was placed on the patient, due to the patient being combative, without revising the patient's earlier restraint order to address the change in restraint type and the change in the reason for the restraint (the earlier restraint order, written on 11/6/14 at 5:55AM, for Patient #3 was for soft bilateral upper extremity restraints with the 'Type of restraint' documented as 'Non-Violent').

Show Text of Violation

Based on interviews and document reviews, it was determined the facility staff failed to ensure patients, with restraints in use for violent or self destructive behavior, were assessed by a physician within one hour of the application of restraints for 2 of 4 patients sampled for restraint use (Patient #1 and Patient #3).

The findings include:

1. Patient #1's clinical record failed to provide evidence of a physician assessment related to restraint use within one (1) hour of restraints being applied for violent or self-destructive behavior.

Review of the facility policy and procedure entitled, Patient Restraint / Seclusion, included the following information: A face-to-face assessment by a physician or LIP (licensed independent practitioner), RN or physician assistant with demonstrated competence, must be done within one hour of restraint / seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. During an interview with Employee #2 (a quality staff member) on 4/16/15 at 8:50AM, Employee #2 reported that a LIP would be a physician assistant or an advanced practice registered nurse (APRN, e.g. a nurse practitioner).

Patient #1's clinical record included an order for restraints written on 8/23/14 at 3:00PM; this order included the following information: Clinical justification of restraint was documented as Physical aggression Locking synthetic leather [sic].

No evidence could be found to indicate Patient #1 was assessed by a physician or an LIP within one (1) hour of having restraints applied for violent or self-destructive behavior. During an interview with Employee #2 (a quality staff member) on 4/17/15 at 11:45AM, Employee #2 reported no physician restraint assessment was found within the first hour of Patient #1 having restraints applied for violent or self-destructive behavior.

2. Patient #3's clinical record failed to provide evidence of a physician assessment related to restraint use within one hour of restraints being applied for violent or self-destructive behavior.

The following nursing note was documented on 11/6/14 at 3:16PM indicated when Patient #3 was placed on restraints for violent or self-destructive behavior: 1300-LATE ENTRY: PT BECAME EXTREMELY AGITATED AND COMBATIVE: TORE OUT IV; TOOK LEADS OFF AND PROCEDED TO GET DRESSED TO LEAVE. CODE STRONG WAS CALLED AND ATTEMPTS WERE MADE TO CALM PT. PT BECAME INCREASINGLY DISTRESSED, ANGRY, AND COMBATIVE; PT WAS RESTRAINED. 20MG [sic] ATIVAN (this was later edited to read as 20 mg haldol) IV GIVEN WITH MEDICAL TDO ORDERED. PT CURRENTLY IN 4 PT (point) LEATHER RESTRAINTS.

Patient #3's clinical record included a physician restraint order documented on 11/6/14 at 8:17PM for Leather X's 4 (four point leather restraints). The 'Type of restraint' was documented as 'Violent / Self Destructive' and the 'Clinical justification of restraint' included 'Violent'. This order replaced the earlier restraint order documented on 11/6/14 at 5:55AM, which was an order for Patient #3 to have soft bilateral upper extremity restraints; the 'Type of restraint' was documented as 'Non-Violent'.

Review of the facility policy and procedure entitled, Patient Restraint / Seclusion, included the following information: A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint / seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. During an interview with Employee #2 (a quality staff member) on 4/16/15 at 8:50AM, Employee #2 reported that a LIP would be a physician assistant or an advanced practice registered nurse (APRN).

No documentation was found in Patient #3's clinical record to indicate the patient was assessed with a face-to-face visit by a physician within one (1) hour of having restraints applied for violent or self-destructive behavior.

Show Text of Violation

Based on interviews and document reviews, it was determined the facility staff failed to ensure a valid medication order was present for a medication administered to Patient #5 and the facility staff failed to ensure an assessment was completed related to a PRN (as needed) medication provided to Patient #5.

The findings include:

A facility staff member administered a medication to Patient #5 without a valid, current order; and a facility staff member administered a PRN (as needed) medication to Patient #5 without assessing and/or monitoring the patient's need for and response to the medication.

Patient #5's medication administration records indicated lorazepam 1mg IV (intravenous) injection was administered on 1/9/15 at 3:26PM. Review of Patient #5's clinical record failed to reveal: (a) documentation to indicate why the patient was given the lorazepam and (b) an evaluation / reassessment after the medication was given to indicate if the desired effect of the lorazepam had been achieved.

During an interview with Employee #2 (a facility quality staff member) on 4/16/15 at 2:45PM, Employee #2 reported the facility did not have a policy that addresses assessment and reassessment for all PRN (as needed) medications; Employee #2 reported the facility's policy only speaks to the assessment and reassessment of pain medications.

Patient #5's medication orders revealed an order for lorazepam 1mg IV every one (1) hour PRN (as needed) for agitation with 'special instructions' of 'Prior to lumbar puncture, may repeat another dose 15 min (minutes) later if needed.' This was the order used to provide the lorazepam to Patient #5 on the afternoon of 1/9/15. (The lumbar puncture for which this medication had been ordered was scheduled of 1/6/15 but was canceled.)

The physician (Physician #1) who had written the aforementioned lorazepam order was interviewed via telephone on 4/16/15 at 1:50PM (the facility's Quality Director was present), Physician #1 reported the lorazepam was ordered to be given to Patient #5 prior to the lumbar puncture only and to be repeated once if needed prior to the lumbar puncture.

During an interview with the facility's Director of Advanced Clinical (DoAC) (with the Quality Director and a Quality RN present) the administration of lorazepam to Patient #5 on 1/9/15 based on the order written on 1/5/15 was discussed. The DoAC reported that the 'special instructions' written in the order which read as Prior to lumbar puncture, may repeat another dose 15 (minutes) later if needed would have been a part of the order the RN had used to administer the lorazepam. The DoAC stated the way the order was written would have indicated a need for the nurse to obtain a new/current order prior to giving Patient #5 the dose of lorazepam on 1/9/15.

No order for the 1/9/15 lorazepam, which was administered to Patient #5, was found by or presented to the survey team.

This is a complaint deficiency.

Respect us. Protect us. Pay us!

LewisGale Hospital - Montgomery

41 CMS Violations since 2015-04-17

Non Immediate Jeopardy Violations

Violation Name: PATIENT RIGHTS(A-0115) toolTips('.tooltip_post_id_custom_bf5e93c6c9435a0fcf479971178a8df9','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A hospital must protect and promote each patients rights\.');

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144) toolTips('.tooltip_post_id_custom_5b0ad3ac79053b01c684d7217015ca1b','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>The patient has the right to receive care in a safe setting\.');

Violation Name: PATIENT RIGHTS(A-0115) toolTips('.tooltip_post_id_custom_021165f3b42f65ea5b7625bfb07a368f','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A hospital must protect and promote each patients rights\.');

Violation Name: PATIENT RIGHTS(A-0115)

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

Violation Name: PATIENT RIGHTS(A-0115)