Initial Comments:
This report is the result of an unannounced onsite complaint investigation (PA00073132) conducted June 13-14, 2024, at PAM Health Specialty Hospital of Pittsburgh, with investigation concluding July 5, 2024. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.
Plan of Correction:
482.13(e)(8) STANDARD
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Name - Component - 00
[Unless superseded by State law that is more restrictive,]
(iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy.
Observations:
Based on review of facility documents and medical records (MR), as well as employee interviews (EMP), it was determined the facility failed to ensure the physical safety of the non-self-destructive patient by renewing the restraint orders as authorized by hospital policy in one of three restraint medical records reviewed (MR3).
Findings include:
Review of "Restraint Policy," revision date March 4, 2022, revealed, "Restraint is initiated only upon the order of a physician or other licensed independent practitioner (LIP) responsible for the patients' care and authorized to order restraint use ... The need for restraints must be reevaluated and orders to renew the use of restraints must be entered at least once weekly ..."
1. Review of MR3, on June 20, 2024, revealed, no physician/licensed independent practitioner restraint order for the time period of February 28-March 11, 2024. Further review revealed that the patient was documented in restraints on those dates.
At approximately 2:27 PM on June 27, 2024, when asked if there were any orders for restraints for the missing time period, EMP1 stated, "I am unable to locate one (restraint order) at this time."
At approximately 11:49 AM on July 5, 2024, EMP1 confirmed that removal of lines and medical equipment is viewed as a non-self-destructive behavioral reason for restraint, per facility policy.
Plan of Correction:A 0173
WHO: The Chief Nursing Officer (CNO) is responsible for overall and ongoing compliance and continued implementation of the plan of correction.
WHAT: The CNO or designee will re-educate registered nursing staff on Nsg Policy 46 Restraints. Specifically, the need for a restraint order weekly.
WHEN: Education will be completed by August 26, 2024.
HOW: Staff will ensure that there is a weekly order for patients who are restrained.
MONITORING ONGOING COMPLIANCE: The CNO, NM, and DQM will audit the medical records on patients who are in restraints to ensure compliance with documentation of orders. Monitoring will continue for one (1) month(s) until compliance has been demonstrated. Once compliance demonstrated, monitoring will occur for one (1) month to determine sustainability. If sustainability is not demonstrated monitoring will continue for one (1) more month. Non-compliance will be addressed immediately, re-education will be instituted, if non-compliance by an employee remains the discipline process will be instituted. Audit results will be reported monthly to QAPI, and quarterly to the Medical Executive Committee and Governing Board.
Initial Comments:
This report is the result of an unannounced onsite complaint investigation (CHL24C437A) conducted June 13-14, 2024, at PAM Health Specialty Hospital of Pittsburgh, with investigation concluding July 5, 2024. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.
Plan of Correction:
103.4 (3) LICENSURE
FUNCTIONS
Name - Component - 00
(3) Take all reasonable steps to
conform to all applicable Federal,
State, and local laws and
regulations.
Observations:
Based on review of facility documentation and medical records (MR), as well as employee interviews (EMP), it was determined that the facility failed to conform to all applicable Federal regulations.
The facility was found to be non-compliance with the following Federal regulation:
- Each order for restraint used to ensure the physical safety of the
non-violent or non-self-destructive patient may be renewed as authorized by hospital
policy.
This is not met as evidenced by:
Based on review of facility documents and medical records (MR), as well as employee interviews (EMP), it was determined the facility failed to ensure the physical safety of the non-self-destructive patient by renewing the restraint orders as authorized by hospital policy in one of three restraint medical records reviewed (MR3).
Findings include:
Review of "Restraint Policy," revision date March 4, 2022, revealed, "Restraint is initiated only upon the order of a physician or other licensed independent practitioner (LIP) responsible for the patients' care and authorized to order restraint use ... The need for restraints must be reevaluated and orders to renew the use of restraints must be entered at least once weekly ..."
1. Review of MR3, on June 20, 2024, revealed, no physician/licensed independent practitioner restraint order for the time period of February 28-March 11, 2024. Further review revealed that the patient was documented in restraints on those dates.
At approximately 2:27 PM on June 27, 2024, when asked if there were any orders for restraints for the missing time period, EMP1 stated, "I am unable to locate one (restraint order) at this time."
At approximately 11:49 AM on July 5, 2024, EMP1 confirmed that removal of lines and medical equipment is viewed as a non-self-destructive behavioral reason for restraint, per facility policy.
Plan of Correction:P 0317
WHO: The Chief Nursing Officer (CNO) is responsible for overall and ongoing compliance and continued implementation of the plan of correction.
WHAT: The CNO or designee will re-educate registered nursing staff on Nsg Policy 46 Restraints. Specifically, the need for a restraint order weekly.
WHEN: Education will be completed by August 26, 2024.
HOW: Staff will ensure that there is a weekly order for patients who are restrained.
MONITORING ONGOING COMPLIANCE: The CNO, NM, and DQM will audit the medical records on patients who are in restraints to ensure compliance with documentation of orders. Monitoring will continue for one (1) month(s) until compliance has been demonstrated. Once compliance demonstrated, monitoring will occur for one (1) month to determine sustainability. If sustainability is not demonstrated monitoring will continue for one (1) more month. Non-compliance will be addressed immediately, re-education will be instituted, if non-compliance by an employee remains the discipline process will be instituted. Audit results will be reported monthly to QAPI, and quarterly to the Medical Executive Committee and Governing Board.
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