Volume 2024 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 15: PATIENT RIGHTS AND SAFETY 15.01.08 Privacy and safety: Safe setting Overview of the requirement:
Tips for compliance:
n Ensure that your policies for assessing patient risk of harm include all departments into which a patient may be admitted. n Train staff on policy and procedure for patients assessed to be at risk of harm to self or others. Ligature points and other environmental risks can arise over time. Conduct regular assessments focused on environmental changes (broken fixtures, items with looping or tying potential, etc.). Act immediately to mitigate identified risks.
Hospitals protect the physical and emotional health and safety of patients through effective risk management. Compliance is evaluated through observation, interview and document review. Most deficiencies focused on unaddressed safety concerns, including lapses in mitigating action for patients assessed at risk of harm to self or for environmental concerns. Similar observations were noted at standards 15.03.01 Identifying patients at risk and 15.03.02 Environmental safety risks although as distinct standards, neither of these reached the threshold of 20% for inclusion in this report.
Comment on deficiencies:
15.02.08 Orders for restraint or seclusion Overview of the requirement:
Hospitals have policies and procedures that identify the categories of licensed practitioners authorized to order restraint or seclusion. All use of restraints (chemical or physical) require documentation in the form of an order prior to application. In an emergent situation, documentation is expected immediately after the restraint has been applied. Compliance is evaluated through policy and medical record review. Deficiencies identified timeliness of documentation as a particular issue, along with gaps between hospital policies and actual practice.
Frequency of citation:
25%
Examples of surveyor findings:
n During observation of a medication pass, the surveyor was informed by the patient that she is blind. There was no disclosure by the nursing staff that the patient had a visual deficit. There were no postings in the patient’s private room of the condition. There was no notice on the main page of the medical record. The only documentation appeared in the admission assessment. This created a safety concern for the patient. n During the tour of the surgical services department (pre-op, surgery, post- anesthesia care, sterile processing), more than 50 unsecured needles and syringes were observed that could be accessed by unlicensed staff n A patient with a chief complaint of suicidal ideation presented in the emergency department. The medical record lacked evidence of a documented screening to identify risk of harm to self or others using a risk assessment tool. The patient was placed in the hallway for ‘close observation,’ but based on surveyor observation, there was no one-on-one monitor in place. n Within the behavioral health unit, five of eight beds have wheeled, height- adjustable overbed tables with drawers typically used in medical patient rooms. The overbed tables pose multiple ligature risk points and the drawers have a potential for hiding contraband. n One of six behavioral health (BH) patient rooms had a shredded window shade. Strings from the shade present a risk of self-harm or harm others. One of six BH patient rooms had broken plastic framing around the window that was sharp and could be used for self-harm or harm others.
Comment on deficiencies:
Frequency of citation:
29%
Examples of surveyor findings:
n A patient was given medications as a chemical restraint. This was noted in the provider’s ED progress note but there was no order completed in the EMR per the hospital’s restraint order process for chemical restraint. n Three of nine medical records for restrained patients lacked documentation of written orders from the physician. n One of three records lacked a timely physician order for restraint after initial application. Based on the interview and nursing note documentation, a verbal order was received on [date], but not documented in the medical record until 12 days later. n Orders did not indicate if the restraints were non-violent or violent. The EMR physician order set did not have an option for identifying violent or non-violent restraints. n Thirteen of twenty-nine restraint orders were placed by an RN as protocol. The timing between orders and the application of restraints showed late entries between four and seven hours after the restraint start time and early entries between eight and ten hours before the application of restraints. n Numerous orders entered by the RN were either not signed by the LIP or physician or had significant delays in order signatures. n Two of seven behavioral health patients under violent restraints had records that included initial orders for lesser restrictive measures, but failed to include the progressive order for violent restraint.
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