Volume 2024 | No. 2
SURVEYOR
CRITICAL ACCESS HOSPITAL
CHAPTER 17: EMERGENCY MANAGEMENT 17.01.06 Evacuation Overview of the requirement:
n Based on record review for non-violent restraints, two of three records had an incomplete plan of care. One was missing resolution of restraint at time of removal. One chart had nothing on the plan of care regarding restraint. n For violent and non-violent restraint use, two of seven medical records did not have evidence of a modification to the patient’s individualized plan of care. n Train all relevant staff on restraint use and requirements for documentation of restraint use. n Train others authorized to order restraints (physicians and other licensed practitioners) on the hospital restraint and seclusion policy. n Conduct medical record audits to ensure restraint documentation compliance.
Policy and procedure must address safe evacuation from the facility when it is not safe to provide care and treatment therein. Compliance is confirmed through review of the emergency operations plan (EOP) and interviews. Deficiencies were noted when the evacuation plan was incomplete based on required elements of the standard.
Tips for complianc e:
Comment on deficiencies:
Frequency of citation:
46%
Examples of surveyor findings:
n The hospital’s emergency evacuation policy did not show evidence of review and reapproval in the past six years. n The emergency operations plan makes no provision for patients who refuse to be evacuated. n The evacuation protocol is detailed within the EOP via a hyperlink to the facility’s intranet policy portal. There was no evidence that the protocol had been shared with, reviewed by, or made accessible to the local community emergency response agency. n The EOP did not include an evacuation plan. n Consider evacuation from the perspective of each unit/department of the CAH based on projected needs of its patients.
16.00.17 Monitoring of the patient
Overview of the requirement:
When restraint of seclusion are used during patient care, intervals for monitoring and reassessment must be defined and performed by qualified staff. Compliance is evaluated through medical record review. Findings focused on failure to implement policy with regard to monitoring time frames.
Comment on deficiencies:
Frequency of citation:
38%
Tips for complianc e:
Examples of surveyor findings:
n For a chart noting the indication for restraints to be both behavioral (violent) and medical, the patient was monitored every one hour instead of every 15 minutes as required by the hospital’s policy. n Across five medical records with orders for non-violent restraints, four were found to have monitoring documentation that exceeded the two hours required by facility policy; one had no monitoring documented for nine hours and 30 minutes for a patient in mitten restraints. n A patient in violent four-point restraints had no documented nursing monitoring from 1815 to 2055 on day one from 0701 to 0800 on day two. The restraint policy requires monitoring every 15 minutes. n Restraints are intended to be used as infrequently as possible and removed as early as possible. Educate staff regarding the policy for monitoring and reassessment.
Identify and document management strategies for evacuation refusal.
n Schedule policy review and reapproval at least every two years. Ensure that the plan has been shared with the community’s emergency response agency with each cycle of review and approval.
17.01.11 Invoking the 1135 Waiver Overview of the requirement:
Tips for complianc e:
Under a federally-declared public health emergency, an 1135 waiver allows for modifications of some CMS requirements for a hospital to continue operating without sanction. Policies and procedures must include the role of the CAH under these circumstances including collaboration with local emergency officials regarding alternate care sites. Compliance is assessed through document review. Surveyors noted that this policy was missing, incomplete, or unapproved.
Comment on deficiencies:
Frequency of citation:
31%
Examples of surveyor findings:
n Written policies and procedures did not address the role and functioning of the hospital under an 1135 Waiver. n The “Policy and Procedures for 1135 Waiver” did not include a date of approval.
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