Crozer Chester Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 41272 Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to follow their approved policy for the use of restraints and failed to use a restraint in accordance with the order of a physician for one of ten medical records reviewed (MR3). Findings include: Review on August 7, 2024, of Policy titled “Restraint and Seclusion Management” with a revision date of July 9, 2024, revealed “... I. POLICY: It is Crozer Health’s desire to create a safe and appropriate environment in keeping with our mission and philosophy to protect patients and others. Restraints or seclusion are used when less restrictive interventions have been determined to be ineffective to protect the patient, staff, or others from harm. Interventions are discontinued at the earliest possible time, regardless of time of order expiration. Restraints/Seclusion are not used as a means of coercion, discipline, convenience or staff retaliation. The hospital uses restraints and seclusion ONLY to protect the immediate physical safety of the patient, staff, or others. ... V. PROCEDURE: To the extent possible, the impending need for behavioral restraint/seclusion is anticipated, and alternative treatments implemented to assist the patient to regain control. ... When behavioral restraint/seclusion is indicated, the following elements must be present: 1. Provider Order a. If conservative, non-physical strategies are unsuccessful in reducing the risk of: a. patient’s behavior, the provider is notified, and if deemed medically appropriate, an order to implement behavioral restraint/seclusion is issued. b. In emergent situations, the professional nurse may implement behavioral restraint/seclusion prior to notification of the provider i. Following emergency implementation, the provider is immediately notified, and an order obtained. c. The order must include the following: i. Date and time of order ii. Rationale for use of behavioral restraint/seclusion iii. Type of Restraint iv. Location of Restraint ...” Review of MR3 on August 8, 2024, revealed the patient was placed in 4-point soft locked violent restraints on July 19, 2024, at 22:00 and discontinued on July 19, 2024, at 23:00. Further review of the MR3 revealed there was no written order for the restraint. Interview with employee EMP5 on August 9, 2024, at approximately 2:00 PM confirmed there was not a restraint order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 41272 Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to follow their approved policy for the use of restraints and failed to ensure that a patient was seen face-to-face within 1 hour after the initiation of a restraint for one of ten medical records reviewed (MR3). Findings include: Review on August 7, 2024, of policy titled “Restraint and Seclusion Management” with a revision date of July 9, 2024, revealed “... I. POLICY: It is Crozer Health’s desire to create a safe and appropriate environment in keeping with our mission and philosophy to protect patients and others. Restraints or seclusion are used when less restrictive interventions have been determined to be ineffective to protect the patient, staff, or others from harm. Interventions are discontinued at the earliest possible time, regardless of time of order expiration. Restraints/Seclusion are not used as a means of coercion, discipline, convenience or staff retaliation. The hospital uses restraints and seclusion ONLY to protect the immediate physical safety of the patient, staff, or others. ... V. PROCEDURE: To the extent possible, the impending need for behavioral restraint/seclusion is anticipated, and alternative treatments implemented to assist the patient to regain control. ... When behavioral restraint/seclusion is indicated, the following elements must be present: ... 2. A LIP (provider, physician assistant, CNPs) must see and evaluate the patient and document the following within one hour after initial implementation of behavioral restraint/seclusion for violent or self-destructive behavior: a. An evaluation of the patient ’ s immediate situation b. The patient’s reaction to the intervention c. The patient’s medical and behavioral condition d. The need to continue or terminate the restraint ...” Review of MR3 on August 8, 2024, revealed the patient was placed in 4-point soft locked violent restraints on July 19, 2024, at 22:00 and discontinued on July 19, 2024, at 23:00. Further review of the MR3 revealed there was no documentation of a physician assessing the patient within 1 hour of being placed in violent restraints. Interview with EMP2 conducted via email on August 12, 2024, confirmed there was not a physician assessment of MR3.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 41272 Based on review of facility policies, medical records (MR), and staff interviews (EMP) it was determined the facility failed to ensure that nursing personnel followed facility policy for patients on cardiac monitoring in three of ten medical records reviewed (MR1, MR4, and MR8). Findings include: On July 2, 2024, review of policy “Telemetry Utilization” with an effective date of October 6, 2021, revealed “POLICY: Telemetry is a supportive tool when taking care of patients who may be at risk for abnormal heart activity. For every patient on telemetry there needs to be a daily assessment for the need of continuous Cardiac monitoring. II. PURPOSE: To guide Crozer Health clinicians in determining which patients require arrhythmia monitoring via telemetry; specifically, initiation, duration, and discontinuation. III. SCOPE: Clinical Practitioners (RNs, MDs, Dos, APRNs, Pas) involved in the care of the patients for whom arrhythmia monitoring via telemetry is being considered at CCMC only. ... V. PROCEDURE: 1. Night shift: utilizing the Daily Telemetry Checklist, each nurse will add their telemetry Patients ... B. Nurse will check Indications met or Does not meet Indications. 2. Day shift: by 9am each nurse will review the list for appropriate outcomes of their patients A. Indications met-continue telemetry and place order per protocol. B. Does not meet Indications-Discontinue Telemetry, make general care and place order per protocol. ... 4. Daily Telemetry Checklist ... B. Fax the completed sheet to the Hospitalist’ Office where all Hospitalist will be alerted about their patients through office team. ... VI. Daily Telemetry Checklist with Appropriate Indications on back. ... 6. Kept in a binder each day for future reference. ... Telemetry Discontinuation Patients on telemetry monitoring will be evaluated by nursing in accordance with the following process. Telemetry Order will automatically discontinue based on the ordered duration (24/48/72 hours, indefinite, or clinical outcome achieved). One hour prior to the order expiration, the Cardiac Telemetry Assessment form task will fire. This assessment includes the following: o RN to assess for safe discontinuation of telemetry or need for new order based on set criteria (vital signs and/or a significant change in clinical condition) ... o If VS unstable, continue with telemetry monitoring. o If the patient meet the clinical criteria the telemetry will be discontinued by the RN. o If the patient does not meet the clinical criteria the RN will contact the provider to determine if another order needs to be placed to continue telemetry.” On July 2, 2024, review of policy “Cardiac Monitoring” with an effective date of May 12, 2022, revealed “POLICY: Monitoring of vital signs, especially heart rate and rhythm, is accomplished through various continuous monitoring devices. A clinical alarm is defined as a patient generated or activated audible and/or visual notification that a patient’s immediate physiological health status is, or could be, life threatening. ... All patients outside the critical care units on telemetry will have an order for telemetry monitoring. All orders remain active until discontinued. ... 9. Standby A. The Standby function allows the clinician to suspend monitoring on a patient. i. While in ‘Standby’ the patient is not monitored at the central station; ... ii. Patients should only be placed in ‘Standby’ when/if a patient travels off the unit on a stand-alone transport monitor, arrives to a department where the telemetry monitor is removed (i.e. MRI, OR) or during a bedside procedure where a portable bedside monitor is used and appropriate clinician is in attendance. ...” Review of MR1 revealed the Cardiac Telemetry Assessment for June 6, 2024, for Telemetry Heart Rate DC (discharge) Criteria trigger “Patient does not meet criteria to automatically discontinue telemetry. Contact provider to evaluate need for new order.” Further review of MR1 revealed there was not a new order to continue telemetry. Nursing Progress Note dated June 9, 2024, at 07:21 for MR1 stated “... Pt [patient] had continuously removed the monitor throughout the night, and was on and off standby as monitor was on and off ...” Patient was found at 0615 with no pulse. There was no physician order to put the telemetry monitoring on standby. Interview with EMP5 on July 2, 2024, confirmed the telemetry order was not renewed. Interview with EMP 7 on July 3, 2024, confirmed there was no order to place telemetry on standby. Review of MR4 revealed an order for telemetry monitoring on May 29, 2024, at 0941 for 24 hours. On May 30, 2024, at 0840 met criteria to continue telemetry monitoring and needed a renewed order. No new order to renew telemetry was found in the medical record. Patient was kept on telemetry, verified by printed out telemetry strips, without an order. Interview with EMP9 and EMP10, on July 3, 2024, at 11:00 AM confirmed that the telemetry order was not renewed and telemetry was continued without an order. Review of MR8 revealed the Cardiac Telemetry assessment triggered but was not completed. Patient was put on telemetry, verified by printed out telemetry strips, without a completed assessment or doctors order for telemetry. Interview with EMP5 on July 3, 2024, at 10:00 AM confirmed the Cardiac Telemetry assessment was not completed and there was not an order for telemetry for MR8.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41272 Based on review of facility documents, medical record (MR), and staff interview (EMP), it was determined that the hospital failed to implement measures to keep a patient, who was deemed incapacitated, safe from eloping from the facility in one of ten medical records reviewed (MR1). Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with the condition of patient rights: 482.13 (c)(2) Patient Rights: Care in a safe setting - The information reviewed during the survey provided evidence that the hospital personnel failed to protect a patient’s rights by failing to keep an incapacitated patient safe from leaving the facility. On February 7, 2024, at 1:57 PM Immediate Jeopardy (IJ) was identified, and the facility was notified regarding its failure to identity elopement behaviors and implement safety measures to keep patients safe. The hospital implemented a plan to include education, assessment changes and audits. On February 7, 2024, at 5:00 PM, the IJ was removed after the State Survey Agency verified that a new assessment was created, staff onsite were educated, a plan was in place to continue education and a house wide audit was completed to identify any other patients at risk to ensure they had interventions in place to prevent an immediate risk. However, noncompliance at the Condition of Participation level remains. Cross reference 482.13 (c)(2) Patient Rights; Care in a Safe Setting”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 41272 Based on review of facility documents, medical record (MR), and staff interview (EMP), it was determined that the hospital failed to implement measures to keep an incapacitated patient safe from eloping from the facility for one of ten medical records reviewed (MR1). Findings include: Review on February 7, 2024, of the facility policy “Patient Rights and Responsibilities” with an effective date of 11/30/2020, revealed “... II. PATIENT RIGHTS AND RESPONSIBILITIES ... Your Rights as a patient, you or your legally responsible party, have the right to care without discrimination due to age, AIDS or HIV status, ancestry, color, culture, disability, education, gender identity, income, language, marital status, national origin, race religious creed, sex, sexual orientation, union membership, or who will pay your bill. As our patient, you have the right to safe, respectful, and dignified care at all times. You will receive services and care that are medically suggested and within the hospital’s services, its stated mission, and required law and regulation ... Visitation: You have the right to: 1. Decide if you want visitors or not while you are here. The hospital may need to limit visitors to better care for you or other patients. 2. Designate those persons who can visit you during your stay. These individuals do not need to be legally related to you. 3. Designate a support person who may determine who can visit you if you become incapacitated ... Care Delivery You have the right to: ... 8. Receive efficient and quality care with high professional standards that are continually maintained and reviewed ...” Review of the facilities security report of incidents revealed on January 19, 2024, at approximately 4:00 PM, “I observed a disturbance in the lobby. Upon further investigation I determined that patient [name redacted] ... who is under guardianship was in the lobby attempting to push through the hospital staff and make ... way to a white male .... The male was later identified as [name redacted], son .... After [name redacted] was allowed to visit with son for a few minutes [name redacted] wad [sic] escorted to room.” Further review of the facilities security report of incidents revealed on January 31, 2024, at approximately 3:35 PM, “I was informed that [name redacted] ... was not in room and could not be located. The decision was made to contact the [name redacted] Police Department because [name redacted] is currently under guardianship ... A search of the building and a review of the camera system were conducted with negative results. ...” Review of MR1 revealed that the patient was admitted to the rehabilitation unit from an outside facility on August 14, 2023. On September 26, 2023, document “COURT OF COMMON PLEAS OF DELAWARE COUNTY PENNSYLVANIA ORPHAN’S COURT DIVISION EXPERT REPORT” revealed, “... PART II: ALLEGED INCAPACITATED PERSON (AIP) 13. ... In your expert opinion, within a reasonable degree of professional certainty and based on your knowledge, skills, experience, and education, is the ATP incapacitated? Yes, totally impaired. ...” Further review of MR1 revealed the patient had been admitted in August 2023, to the rehabilitation unit. On September 12, 2023, patient was transferred to the second-floor medical surg unit for a change in condition. The patient resided on the second-floor unit until January 31, 2024, date of the elopement incident. Patient was ambulatory on the unit and was awaiting guardianship for placement. Nursing progress note on September 21, 2023, revealed a staff member found the patient in the lobby area, and the staff were made aware that the patient was a flight risk. The nursing note on January 31, 2024, stated “nurse was alerted by the MD (Medical Doctor) that the pt (patient) was not in room around 1400 when he went in to complete his assessment. Nurse immediately went to the pts room where she checked to see if the pt was in the restroom and the pt was not in the room. Nurse alerted the other nursing staff and they all checked the unit as the pt is known to wander to talk to other staff. When the pt was not found on the unit the nurse immediately notified the nursing director. The nursing director and other staff checked other parts of the hospital and outside surrounding areas. Security was notified by the nurse. Police were notified and the nurse gave a statement. Pt appears to have left behind all belongings except ... cell phone. Pt also appears to have changed ... clothes and left without her shoes.” Interview with EMP1 on February 6, 2024, at approximately 11:00 AM revealed that the police had located the patient six days after eloping from the hospital, in a hotel room in another state. EMP1 stated the police then took the patient to a nearby hospital emergency room for evaluation in that state. Interview with EMP7 on February 7, 2024, at approximately 11:30 AM revealed the patient did leave the unit one time before and made it to the lobby. EMP7 was in the lobby talking with the son who refused to leave, and EMP7 intercepted the patient from going into the lobby. The patient was aware that son was in lobby as had talked to the son on the patient’s cell phone. The son had previously been restricted from visiting. EMP7 confirmed there was not any interventions in place at that time and stated security would have stopped patient. Patient was then moved closer to the nurse’s desk and staff confiscated the patient’s phone. EMP7 stated that the patient was not understanding, would become agitated, and was not always easily redirected. EMP7 confirmed the patients care plan did not address elopement risks. Interview with EMP6 on February 7, 2024, confirmed that there were no interventions put in place for the patient when was found in the lobby on January 19, 2024, other than moving closer to the nurse’s station.”