PRINTED: 08/08/2015 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAIO SERVICES, OMB NO. 0938-0391 [STATEMENT OF DEFICIENCIES 0K!) PROVIDERISUPPLERIGLA | 0&2) MULTIPLE CONSTRUCTION [ox oxre sunvey [AND PUAN OF CORRECTION IGENTIRICATIONNUMBER’ — | mn on, (COMPLETED c 4190035 e.wING Sainte 07/23/2018 THANE OF PROVIDER OR SUPPLIER STREET ADDRESS, CIN, STATE, EP CODE 4 MEDICAL VILLAGE DRIVE ‘STELIZABETH MEDICAL CENTER Encewogn ny acty or) ‘SURMARY STATEMENT OF DEFIOIENGIES D PROVIDERS PLAN OF CORRECTION 2 Sheet | (EACH DEFICIENCY NUST BE PRECEDED BY FULL PREC (AGHCORRECTNE ACTION SHOLLOBE | conbtttion The | REGULATORY ORLSC IDENTIFYING INFORMATION) Tae AOSS REPERENGSD foTRe APPROPRIATE |” ONTE DEFICIENCY) A000] INITIAL COMMENTS A000) A Complaint Survey investigating KY00023514 was conducted 07/14/15 through 07/20/46, to determine compliance with Federal Certification requirements related to the allegations of the complaint. The Compiaint Survey found the facity to be in compliance with certification requirements and KY00023514 was substantiated. | LABORATORY DIRECTORS OR PROVIDETISUPPLER REPRESENTATINES SIGNATURE THLE Coane ‘ny datceny statorent ending with an asleisk (>) denotes a defcloncy which the insttalon may be excused from correcing providing tls dotermined that other safeguards provde sufclentprotecion to ho palens. (Soo inctucions.) Except for nursing homes, the findings slated above are disciosable 90 days following the dat of survey whether or nota plan of eotecton's provided. For nusing homes, the above ndings and plane of correction ara disclosablo 14 ays lolowing the date these documenls are made evazabie fo th faclty. If diiences are cited, an approved plan of corecton Is requisite to continued program participation FORM CNS 266712.9) Previous Verlons Obsokte evetibsetvant acy 10100272 Woontiwation sheet Page 1 of 1PRINTED: 09/24/2015 FORM APPROVED Office of Inspector General ‘STATEMENT OF DEFICENGES | Xt) PROVIDERIGUPPLIUGUA | (X2) MULTIPLE CONSTRUOTION [pay DATE SURVEY [AND PLAN OF CORRECTION IDENTIFICATON NUMBER” — |S auton: coneuereo RC 400272 awe 09/24/2015 [NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, 21P CODE 4 MEDICAL VILLAGE DRIVE ‘ST ELIZABETH MEDICAL CENTER Tegewoon Kate? cor) SUMMARY STATEMENT OF DEFIGENCIES 0 'PROVIGERS PLAN OF CORRECTION rm) Pheri | [EACH DEFICIENGY MUST BE PRECEDED BY FULL REED (ACH CoRRECTIVeACTIONSHOULDBE | colbteTE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAS ‘CROSS-REFERENGED TO THE APPROPRIATE. | OKTE | DEFICIENCY) {E000} 902 KAR 20:180 Initial Comments (€ 000) ‘An On-site Revisit Survey was conducted (09/23/15 through 09/24/15, Based on the facility's acceptable Pian of Correction, it was determined the facilly was in compliance on 08/28/15 as alleged. LABORATORY DIRECTORS OR PROVIDER/SUPPLIER REPRESENTATIVES SIGNATURE me eqyoare STATE FORE Coal aura T eanimaion saat VaV7PRINTED: Ueio6/2015 'FORMAPPROVED Office of inspector Genera: Oe ore pencencies [Om pROvieRSueRERaIK | 0”) TARE CONSTRUCTION Ta oare SUEY BRO PLANOF CORRECTION DENTICATONMUMUER | 4 RULONG eoweuereD c | soozr2 8. ——— = 07/23/2015 NAME OF PROVIEROR SUPPLIER ST ELIZABETH MEDICAL CENTER ‘GEREET ADRESS, CITY, STATE. 1° CODE 4 MEDICAL VILLAGE DRIVE EDGEWOOD, KY 41017 5 sar SATEEN OF DEPCENOES D SBE PN CORRECTION wi FES ccxcuoencenor sr ae enecepenar ran, prc ._(EACRODRRECTUE ACTION SHONROSE. Ose ok elevoniscwememenromaen Sstetcaororenrnemas 000, 902 KAR 20:180 Initial Comments Tova | Pease accept this Plan af Coreection a¢ : | Esabeth Healthcare -Edgewood's credible | A Complaint Survey investigating KYO0023514 | ' aStegation of compliance effective August30> was conducted 07/14/16 through 07/20/15. 1 4 2015. ire 4 wae susantintes with deiconcies ot 902 KAR 20:80 Section 3. Administration : and Operation 200092 KAR 20:180 Section 9. Administration and £200 + Operation 4 Patient eights. A hospital hall sure at | {_ patient rights are provided pursuant toKRS (4) Patient rights. ‘Ahospital shall assure that | * Chapters 202A end 2028, ‘The Statement of CM gates are provdad pursuant 1OKRS =: Defblences noted, "the fact allel , Grapers 2028 and 2028 1 1 feport suspected neglect andor abuseto he } | seette slate Agence” fr one alent “This requiromont is not met as evidenced by + pa unary, we reised ou pion " Basod on abservaton, nervous. ecard reviow Jesu er Report ot Wins | and review of the facitys pote) : “Abuse, Neglect, Exploitatfon and Domestic ‘determined the facility failed fo roport| to i 1 Violence,” we re-esiucated all facility sail 1 eepocted neglect and or abuse to the | yen te lng blatens and £ Appropriate State Agencies for one (1) often (10) | 1 their mandatory por Sampled patients (Patient #4) sre initiated a process onthe gevitrie : Bationts (Patient ) : behavioral health wnit which yrovides dail Fane A cas restrained by Caciy staff on the | |, debavira eal aera Freriarcspsychiatic (gero-psych) unit for ' | eminders to safreinfrcing te ned for eereonimately eight (@) hours wathout being mandatory oporting whenever there i eepaoed avery two (2) hours and without 1 Taasonable cause to suspect that such abuse ; Physilan notification. \ | tec nme i | cccurred. Specifically ‘The ndings include i 1 Ree Dieetor of Rsk Management 722/15 i | | eueived Reporting Bucation on 2%, Review of the facility's: policy tiled. identification | 1 2015, in the form of a Prevention Plan, which ‘and Reporting of Vietims of Abuse, Neglect, | dhe Director of Risk Management signed, SXpotation ano Domestic Vielen” | aoa one KS, dese epee | ACLIN-A-O, revised '07/24/14, revealed Kentucky} 5 etadatk Maltceatment; wl educate staff om 1 State Law required mandatory reporting of abuse + errr guidelines wl ensure KRSis teers, ouch a8, the elderly ora parson with | Clow nb AD) ‘a disability and children to the. appropriate Stato ; Rgoncy. Per the Policy nage! was defined as 1 tear of a person to had oad assured | epee orfractuat obligation for sonata 13 ie me 9) 067E \ ie ECE eh sey SATEFORM aa Temicatonsnoe FTO SEP 01 206PRINTED: 00/06/2045 FORM APPROVED Office of inspector General ee STATEMENT OF DEFICIENCIES | 08) Saomaensunruercnn | OD MULTPLE “CONSTRUCTION (oe) DATE SURVEY | SHO PLAN OF CORRECTION PRR TONNUNBER. | A BULDNG: COMPETED c 400272 WING 7/23/2015 NAME OF PROVIDER OR SUPPLIER SeREET ADORESS, CITY. STATE, 2 CODE ‘4 MEDICAL VILLAGE DRIVE 7 ICAL CEN ST ELIZABETH MEDICAL CENTER 1 OOD.KY HOT ea “Sanaa STATENENT OF GEEOENCIS, © FRGVIOERS PLAWOF CORRECTION 8) Baio enc ETE HE By FULL REE (ERENGORRECTIE ACTION SHOUD, conte HEF eunATORY ORLSC DENTIEVINS INFORMATION) ae ROSS REFERENCED TO ENF APPROPRIATE DATE SFGINCY) E200; Continued From page t caring for a person, or who had voluntarily cared responsiblity for the person's 2 to provide proper care, food shelter, ‘control and. 1 eapervsion, education, ciothing or ene? ‘which imental Tgvealed all facily staff wero expec reriote to the policy. In adaion, the Fly noted | ade Worker would report allegations of || tre oinaghect to ve appropriate State Agen aoepan the hous of 8:00 AM and 4:30 FM. and | bolo gaato supervisor or the Nurse SUBST | [tae rte the appropriate State Agency afer 4:30 PM. Review of the fac’s paiy tiled, "Resiaint (ratio Seclusion’, ACLIN-R-03, roves 9/23/14, ‘be imposed rust be discontinued at the earliest possible time (tine. * Roview of the facility’, "Patient Righ's and | Responsiblites” document ‘undated, revealed pationts recelving services at the fa had the _ ight to be ffee from unwarranted of Tigh Seonable use of restraints of SeClus or harassment, record reviow reveated the faclty admiine | Pationt #4 on 08/28/15, with diagnoses whi | included Dementia with Severe Behavioral Brsturbances, Alzheimer's Disease and Organic Record review revealed Patient | (FA was, ‘referred to the facility’s gero-psych unit by } * Brain Syndrome. TATE FORM. scented all patients had the right 10 bo «Pee from physical or manta abuse and corporal veprishment, and trom restraint of seca «pum oley, straint andlor soclusion mht only | selsngure the immediate physical + peraty of a patient, slasf member of One, and \ | ion and eam all forms of abuse, negfect exeiotalon- ' + fea p merly “ACUIN-AOL, identification and Reporting of ‘committed by aSt Fe (10,2015. abit 4-2) i | | domestic violence has occursed. | Seetoar anno. \ la, ee as revised inthe section rated 6 Jastances when actial or suspected physical or tape of patient isbeieved tohave Been Elizabeth Healthcare ‘committed | \ rie, Neglect, Exploitation and Domestig 1 1 rate, of is believed to have Been gt Eltabeth Healthcare property Tranguage was added to state, “The Risk a penent Department ay stitute HO Mane teation bat any sich investigation wil Vet rege amely mandatory porting oun 9 ety natter what te Risk Management [Deparment interal(or condced outside poeraee investigation revels DPropeate i [ater il be reported to CHES whee there \ ra gonable case to suspect that such sb ise j neglect, expotation of domes violence hat \ [eect arp nase of AUB 3, All (Qhere are two) members of the Risk | Management Department were educated the poly changes, and reminded of he need for only report to Cabinet of Health and Family | rare whenever theres reasonable aust espect that such abuse neglect e=PLOK=N09 "This education (iehibit A-3) ‘Ai Saciity staff were educated on the s/lo/is (ection G) anions 8/28/15 |r eaten stachingscooy ofthereieel presentation. This education and avast \ + revised policy (Exhibit A2) sia electronic a ei and were provided a eminde of peli ration material on dentifing sm |arpoting use with acopy ofthe ammaey | reminder [oscred asf Angst 28 2015 (Exhibit A-4) Heantouaton sheet 20PRINTED: 08/0612015 FORM APPROVED Office of Inspector General Oe ee ers | iy PaOmBERISURRLRSLA | HA HULTINE CONSIEUCTON [aaponte SURRY [ANOPLAN OF CORRECTION ennptcanowsumee® | a puLONG: cousLeTeD c _ 400272 BING 07/23/2018 NAME OF PROVIDER OR SUPPLIER SIREET ADDRESS, CITY, STATE, 21° CODE { MEDICAL VILLAGE DRIVE ELIZA cl 'STELIZABETH MEDICAL CENTER LMSEWOOD, KY #1017 ayo ‘FONLARY STATENENT OF BEFICIENGIES . PROVIDERS PLAN GF CORRECTION ry YD geqGHOEPIIENEY MUSt BF PRECEDED BY FUL, pert CC RUORRECTIEAGTIONSHOULODE + COMEETE REE | CERETIATORY OR LSC IDENTIFYING INFORMATION) He eRe SeRRenceD TOTREAPPROPRIATE ONE ‘ DEFICIENCY) = ; | € 260, Continued From page 2 J e200 | 5, ABH) focused performance ; 50 jevelope ¥ the long term care facility in which he/she i improvement project was developed to 8/28/15 resided, for evaluation of combative behavior, | ensure appropriate reporting of buss, which had become violent at times, and for neglect, exploitation or domestic violence frequent falls | during each shift, ‘The Behavioral Health | Review of tho faclitys video on 7/17/46, for the Gates of 07/01/15 and 07/02/18, revealed at 0:20 PM Certified Nursing Assistant (CNA) #2 and ‘another unidentified CNA wedged (wo (2) chairs al the back of the chair of Patient i's geri-chalr {apecialized reclining chai) and a door frame preventing the patient from rectining the chalt's Back, Video review revealed Patient #4’s bilateral | Tower extremities were elevated on the ervehair’s footrest. The video revealed a table | was also then positioned over Patient 4's { Slevated bilateral lower legs and lower abdomen | preventing the patient from freely moving his/her ower legs. Continued review of the video | revealed over the next eight (8) hours, Patient #4 | ‘continued to be prevented from rectining the back | of the geri-chair and {o have the table sti positioned in place preventing {ree movement of | {he patient's bilateral lower extremities. Further video review revealed approximately eight (8) hours after initiation of the restraining interventions, CNA #7, who had just reported to; nork and RN #4 were observed toremove Patient #4 from the restraining interventions at 5:00 AM. \ i i Interview, on 07/16/15 at 3:40 PM, with RN #1, | who had been employed by the facly fof ove purse for Patient #4 on the 3:00 PM to 11:00 PM ‘Shift on 07/01/15, revealed the patient had been | very difficult to take care of, very confused, Tate FORM, \ vie op yoare and who was the primary car | | Combative and unsteady on hisiher feet. RN #1 | Stated Patient #4 had been placed in a recliner Shai which was then placed under a table on the | ‘unit's leadership (consisting ofthe nurse | tmanager, charge nurses, and shift | eupervisors) will review with al staff any reports or observations of abuse, neglect, | exploitation or domestic violence, The goal + Gfthe focused study is to ensure that associates appropriately report any actual of ‘nspected abuse, neglect, exploitation or | domestic violence during their shit. The performance improvement project will pontine until chere isa sixteen-week period | without any fare to report suspected abuse Grineplet onthe BEL unit. The performance {improvement project started on August 28 2015. (Exhibit A-5) During the review period, ifa problem is noted, the situation Fil be immediately corrected by reporting Up the chain of command tothe Vice President ff Nursing, The event willbe reported 10: ‘Cabinet of Health and Family Services as pet the poliey ACLIN-A-O1. (Exhibit A-2) Any involved associates will be counseled through the hospita’s progeesive disciplinary process and, provided they are ot terminated, will De Te-educated on appropriate reporting practices. (Exhibit A-2) After the sisteen fveek period without an inappropriate report ‘mission, the Facility will continue to perform | he review for a period of six months to | ensure continued compliance of the 4 ppeopriate reporting by the BEL associates; \ \ auvatt eontuaton sheet of 10PRINTED: 06/06/2018 FORM APPROVED _Dilce of Inspector Ganesal SIATENENT OF DEFICIENCIES SND PLAN OF CORRECTION “Ba TTI CONSTRUCTION ay DATE SURVEY COMPLETED A QULONG: SAO UDERSUPMLERCLA ra IDENTIFICATION HUMBER c B.wINe 07/23/2018. __ 190272, - “STREET ADDRESS, CTY, STATE, 2°. CODE { MEDICAL VILLAGE DRIVE EDGEWOOD, KY 41017 ‘yale OF PROVIDER OR SUPPLIER ST ELIZABETH MEDICAL CENTER oa SiamIARY STATERENT OF DEFTONES ny FROMIGERS PLAN OF CORRECTION oS), PRE iS enY MUST BE PRECEDED BY TULL, PREFIX eee action sxOUOBE, | “Brie TAS EGER sro csc IDENTIFYING INFORMATION As chi REFERENCED TO THE APPROPRIATE OnE i DEFICIENCY) Te 700 | Theresults ofthe performance improvement © 280 Continued From page 3 | stecrations of the BEI unit wil be reported eae Quality Coordinating Counel by the 10 tananager andor the Vice President of Nursing. At the conciusion ofthe formal | performance improvement process BHL 1 eemaingleadership (consisting, of, the URE puveger, the charge muses and the nurse supervisors) evening of 07/01/15, RNY eveated when sta | eer esiraint for 2 patient the Physician was | aye notified; howaver, RN # 1 had not \ _ Sonigeted the Physician on O701715, ot the Sable was plaoed over Patient #4's legs wie his/her legs were elevated in the geri-chair as that| etc restiaint, Further iniorvew revealed | RIN HT did not consider the table wth the Wo 2 | BI A eet athe back of he gore teeta «monthly focused dy wii freventing the back rom rectining 2 arestraint | Pasting performance improvement piso andf | cinta contin ob reviewed ande either. « nterview, on 07/16/15 at 3:25 PM, with CNA EZ, tee ted inthe care of Pationt #4 on the $290 wera 11:00 PM shill on 07/01/15, cevealed she Fomembered the patent playing with the [therapeutic wator bags and beach ball used on Ihe unit, CNA G2 stated however, sho da net \ « emomber placing a table ovo) Pationt #4's lower cere or placing two (2) chairs atthe back of| the patient's chair, even though the Sune | Ghserved GNA #2 performing those actions Geo facillys video. Per intorviow, restraints wre | ut ot the scope of her practice and ne eine out fare of that and oot Physician's Orders oF took cars. continued interview ravected CNABE, | {recalled on the evening of 7/00/75, ‘assisting with! reader scan and toleting of Patient #4. CNA \ $e ated she also assisted Patient #4 with eating | te tain, and had applied alavender skin 1 _Tetion on the patient's sin. \ | interview, on 07/21/15 at 2:00 PM,with CNAHT, | Inter orked atte fait for exh (8) Yours, | a \ ne ad arved for work on 7102/15 at 00 AML. ‘GNA #7 stated Patient #4 was siting in 2 i Wrrived for work that morcing. Pet | wher ur, she also observed a table in ont of « Bient fed and a chair on the other side of the \ ‘TATE FORM | ported to the Quality ‘Coordinating Councit Pomontity, by the BELT nurse manager or the | Vice President of Nursing \ | avait eaniuation shest 4 ofPRINFED: 08/06/2015 FORM APPROVED fice of inspector General Offa of inspector Senetel 5 waenpENeIRRCRRR | Haven € CONSTRUCTION aay ATE SURE AND PLAN OF CORRECTION eeWpexron muses — |, guLone: COMPLETED c ___ 190272 8.WING 0712312018 [SIREEY ADRESS, CiTY, STATE. 2 CODE { MEDICAL, VILLAGE DRIVE NAME OF PROVIDER OR SUPPLIER el ST ELIZABETH MEDICAL CENTER tNSewoon, KY 41017 0 SURRIARY SyATENENT OF OEFIGIENCES D. PROVIDERS PLAN OF CORRECTION 5), BRO Gens DEFICIENCY NUST BE PRECEDED BY FN PREF (ROR CORREDTIVE ACTION SHOUD DE COnRIETE TAG HEAR OR USC IDENTIFYING INFORMATION) TAS CAGSS REPERENCED TO THE APPROPRIATE OMT tl DEFICIENCY) L € 280. Continued From page 4 | £280 table, CNA 87 stated the nurse wanted to tollet Patient #4 after she arrived for work, and when | they both went to pull the patients chair oul from | Undor the lable they both felt cesistance. CNA # | Y'stated when she and the nurse got Patient #48) gor-chair out from under the ‘abl, they observed | Bio (2) of the unit's therapeutic water bags ving | Sa top of the patient's lower fegs. According to CNA #7, RN i#4 removed the therapeutic water tags from Patient #4's legs, and they observed | tome red marks, more lke lines on hisrher Yegs. \ Interview, on 07/23/14 at 10:55 AM, with the || NRPRN for the facility gero-psych unit revealed she nas not aware of any nurses calling to request an} veder for restcaints for Patient #4 during hisiher | oe csion to the faci. The APRN stated when | 3 palient on a psychiatric unit was placed in | a Pitants, a house Psychiatrist had to do a head | to too assessment avery shift while the patient _ remained in rostants. Per interview, she had 04) heen aware of any abuse or neglect issues regarding Patient #4 during hisiner admission. | | Fecther interview revealed, Patient #4 had been ‘admitted to the gero-psych unit related to Dementia and Behavioral Issues, and medical | Daft was assessing the patient's health status | ‘and readjusting hisfher medication regime, Interview, on 07/23 /15 at 10:00 AM, with the Unit | \ Manager (UM) of the facility gero-psych i bohavioral unl revealed two (2) staff members had approached her on the morning of 7702/45, | fegarding Patient #4's care. Per interview this | prompted her to review the video from the \ \ i \ ) previous day, 07/01/15, ane! easly morning hours Proziozi15. The UM stated after reviewing the Video, she contacted the Vico President of Nursing Service, who was on personal leave. Further interviow revealed the VIP of Nursing TATE FORM om auyatt eortraton stack Got 10PRINTED: 0B/08/2015 FORM APPROVED Office of inspector General ae TOE DerCENIES [KD PROWDER SU et “aA ARTE CONSTROGTION ai DATE SURVEY SND pLAIIOR CORRECTION FROMMER | a GURDING: COMPLETED c 400272 WING a ne 07/23/2018 NAME OF PROVIDER OR SUPPLIER GIREET ADDRESS. CITY. STATE. 21° CODE 4 MEDICAL VILLAGE DRIVE $1 ELIZABETH MEDICAL CENTER {Me rrooD, KY 1017 ro Simin STATEMENT OF DEFENCES To FRVIDERS PLAN OF CORRECTION 8, OM ote na anna pee ‘emi ebimecrwencrionsrouDes | pre's EEK (EAE on ON L9C DENTIFYING IFORMATION. TAG. cf nereneges 10 THE APPROPTNTE ate ” € 280" Continued From page 5 [e280 | Services referred her to the facility’ Risk \ : Management for reporting he incident involving \ Managryas care. The UM stated she notified |) | rats isk Management who tok over and frandled the investigation into the incident \ | nterviow, on O7/16/18 ot 1:00PM, with the | ! Hretor of Risk Managemect,reveotod after Peeing a phone call from the UM of ihe } _ Soterpayen betavora un on the morning of \ seroarta. an oulside agency was contacted ard ooucted the investigation and interviesna of correlates to the incident involving Patent A's ae sper interview, the alforney rom the outs catioy wing conducted tne investigation Wt ager etiy out ofthe counisy and unavailable for stow, The Director of Risk Management inter however, he did have the completed ‘evestigation report and could address any | Gonoerns regarding the investigation. ‘Continued cow reveked during the investigation, te int aff involved withthe care of Patient i ra OA/tS and on 07/02/15 were removed from ; Patient care, intervewod, re-educatod 2nd | Piped to return to pationt care after the alomigalion wes conciuded. According to He ee Gr of Risk Management, the results ofthe | Direct on showed no evidence ofintenonal, | «mati conduct by the unt staff and irr | \ | { | mate Moneluded there had bean a mistake on the part of the facility in aot proving education 1° Pa employees regarding the use of the therapoutic waler bags. He slaled, a8 wae, ; determined no abuso oF neglect had occurred | \ i cet caro of Patient #4, there nad been 9 vi tS report the incident to the appropriate | Grate Agencies. The Surveyor requested | sate facitys investigation report during the | «interview, however, the Dect of Risk \ \ i Fretegoment and the attorney representative who \ YATE FORM om avant iteentmaon chest GoOffice of inspector General PRINTED: 08/06/2015 FORM APPROVED Ria) DATE SURVEY a | program Os Or DEricNceeS |) PROVIDERS Te FART CONSTRUCTION RNOPLAN OF CORRECTION PRowpermonnumer — | 4 pULONS: COMPLETED c ie ae 400272 WING eee 97/23/2018, ANE OF PROVDEROR SUPPLIER SIREET ADORESS, CITY. STATE, 21P CODE 4 MEDICAL VILLAGE DRIVE 7 ELIZABETH MEDICAL CENTER Lee NOOD. KY #1047 on hanRY STATEMENT OF OFFENCES, © FRONTERA OF CORRECTION 5), ajo ceqanitenceney NE EEO om) | REE cee wSerecvencTONsrOUD ne Same" BERD denon ON Loc DENTIEYNG RF ORMATION) ae eet eoRRE Reem rome APPROPRIATE ONE i ; DEFICIENCY) £200! Continued From page © 280 \ 7.820 902 KAR 20:180 Sections Patient was present from the outside agency, roused {0 \ Management ‘low the review and stated the facility's : i in investigation report was considered {0 Be attorney! (@) Special treatment procedures client privilege. \ \ | (o,‘theuseof physi restrain and Interview, on 07/23/15 at 4:50 PM. with the VIP of \ ‘seclusion shall be governed by the following: Hitesing Services, who was responsible forthe | FRestaint or seclusion shall be vsed only to Soforpsych unit, revealed when she was noifiog prevent a patient fom injaing himself getig UM on 07/02/15, she immediately referee Pipers, orto prevent serious disruption of te UM to the facility's Risk Manager as she was \ the therapentic program ‘on personal leave and unable to provide i \ ' on Stance. The VIP of Nursing Services stated | he following are actions taken tome Feo faailly had a tendency to over-eact and ever | “tated standard: epot ineldanis. Per interview, the faciiy Flt they had done due diigence regarding the The therapeutic water ans Inetient involving Patient #4's care, and! it was ja he terapetie water Pa + fecenced inthe document were removed MSjgrmined no intentional abuse had OCCuTEGs ets nen the BE depart o8 age i from patient use on depart therefore, twas not reported. | 1 aly 2, 2015, with no plans for introduction i {nto the unit i 870; 902 KAR 20:180 Secon 4. Patent Management | eo | (3) Special treatment procedures. \ | i a Uponreportingoftheincidenton | 7/18 (c) The use of physical restraints and seclusion | Jily 2, 2018, shift uddles were conducted on | Shall be governed by the following ants for immediate re-education of the fs icy Uexhibit 5). + avant or setn sa Yous 9 | est param prevori a patient from injuring himself > oe | i Prey pravent serious disruption ofthe therapeu \ \ 3. ‘the BHI uoithas been monitored 7/9/2018 | pny yh marge the oe | L \ \ verequirement is not met as evidenced DY: | Based on observation, interview, record review sand review of the facility's policy, twas | anttyanined the facity failed to ensure restraints > Gotertjeod only to prevent patients from harming | themselves or others or to prevent serious: | Garuption of the therapautic program for one (4) Of ten (10) sampled patients (Patient WA), | \ ‘TWTE FORM ws arses, and the shift supervisors from the THmneat the event on fly 2 2015;t0the | | presenta formal ies : Fnpsovement pan, (Exhibit E-2) To date 80 further problems have been identiied with restraint practices 1 auyatt teeninaen shoot 704%PRINTED: 0806/2015 FORM APPROVED Office of inspector General Hie oor oecENCES | Ok) PROVEN SUPT Sree Tey WanTIBLE CONSTRUCTION ay onTE SURVEY SND PLAN OF CORRECTION FagveermonwuNeE® |, BULDING COMPLETED c Hee ae 400272 — 07/23/2015. ‘NAME OF PROVIDER OR SUPPLIER “STREET ADORESS. CTY, STATE, 2” COOE 4 MEDICAL VILLAGE DRIVE ‘ST ELIZABETH MEDIGAL CENTER ae NOOD, KY 41017 yO “Sia STATENENT OF DEFICIENOEES © PROVIDERS PLANOF CORRECTION 7 PER encOEFIENCY UST re PREF embencerie AETONSHOUD BE. SET BEE deat ON DENTIFYNG ORATION) ‘ne cH SORRERceD ro meRRPROPAIATE ONE ‘erICNCN) © 8201 Continued From page 7 Tes | ‘Didactic education was provided, nas |, “etewing the use of restraints according tO Patient #44 was sitting in a geri-chat (@ \ [ese Resrnt anVox Seclusion policy Specialized recliner) with the footrest elevated On| jae ina oc, The eteaton A spit, ‘Therapeutic water bags were placed : \ pas completed on July 14,2015. The BUL over Pationt a's lower legs an 9 a ( Matton and teaing used te master Hist of placed over top of his/her elevated lower i iit associ eat al associates Reaeetaties restricting the patient's ability 10 freely | BHI associates to ensure Ot . ory isihet 18. received the education and training containg i \ thin the plan, (Exhibit B-6) Goals and “The findings include: } ‘bjectives of the didactic restraint edacation \ Stang with the lesson pla, are contained Review ofthe factiys poi tiled, "Restraint | | jhin ahi Bt, Special tenon ofthe pevfor Saclusion” ACLIN-R-03, revised 09/23/14 \ 1 Mucation was directed to the definition of 2 aaeeeied all palients had the right to be free from | straint wich i inclusive of any manual + retiraint andlor seclusion, of any form imposed; + inehod, physical oF mechanical device, resyaltans of coercion, csapine, convenience, | | ertal or equipment that immobilizes oF 38 a ation by slaff. According to the Policy, | | reinces the bility of patient to move Bi festraint andior sectusion might only be i | fer arms legs, body, of hea ely and hich implemented to ensure the immediate physical | et pot be easly removed by the patient. aoty of a patient, other patients or staff i \ ert ve document se ith didactic sale ors, and should be discontinued atte | Supe presentation azeinckded in Denigst possible time. The Policy defined & _ ucatons ggies tthe completion of Pastraint as any manual method, physical oF cet anical dovise, Material, oF equipment which ftumobtized or reduced the abilly of patient to rrarretnsiner arms, logs, body, oF head freely and root could not be easily removed by the patient. | Policy review revealod staf were 10 assess, repnitor and document the use of restraints 'O | | followed the didactic restraint (raining t acing: Physician nalifeation; visual observation consisted of 10 questions. | ‘ance of range of {anibivB-3) A score of 9086 was required to of patient in restraints, perform fnation (ROM), skin assessmont and ciroulation pase the est, Any questions missed were viewed at dat time with the stafFt0 ens} ‘Shacks every two (2) hours and vital signs every four (4) hours; offering fuids and ballroom or ‘Tnderstanding of all key components of bedpan use every two (2) hours whe the pationt fedveation, The associates were required 10 was awake, assessing fa less restricive retest to ensure understanding of ll ras ton might be appropriate, ustticaion of wee nal components. AIL BH associates | ctinuad use of every two (2) hours; providing ccm master ist passed the tes \ the education completed axesraint est, The vase template is inchuded in Exhibit 3. sMurendence signin sheets with dates of | autendance for rsiaint education ae aeeiable in Exhibit B-4. ‘The restraint test thet \ \ personel hylene no fess than every twenty four Exhibit B6 (24) hours; and educating the patient andor | ee i eat of the reason for ad ype ofretralnt used ! \ TATE FORM “ avant Aeoniouaon shes! GoPRINTED: 08/06/2015 FORM APPROVED Office of Inspector General SE TOF BERCENCES | (i) PROVDEREUT Fea) MULTIPLE CONSTRUCTION ay DATE GURY BAND PLAN OF CORRECTION PROVE TONNUMBER | a BULDING COMPLETED c 400272 B.WING ee 07/23/2015, [NAME OF PROVIDER OR SUPPLIER “STREET ADDRESS, CITY, STATE, 21° CODE |; MEDICAL VILLAGE DRIVE ST ELIZABETH MEDICAL CENTER EDGEWOOD, KY 41017 m0 “Sinn STATENteT OF DEF GENOIES © FRONDERS PUN OF CORRECTION. 9, yO, LeACHLBRPCIENEY HUST ES pReeix contgitcenee nevom swouoee gree REM | eSiiaton OR LSC IDENTIFYING NFORMATON, “ae cas reverence rome aePrOPATE bare —820| Continued From page 8 Zam | A restraint practicum was a Further review revealed staf were walned on, | | provided on August 7, 2015,0n se ens Fefoint use during orientation and periodically [see according ACN ce ff afterwards. \ ‘and/or Seclusion policy to : \ [BATT clinical associates. The BH review ofthe facts, Patient Rigs 2nd | | practicum wad the mast it Rocponsibities”, undated, roves patients Were) \ PH associates to ensure that all To be free from ail fonms of abuse and negleck. | esociates participated in the practicum. -Furthor review reveled patients wer Loe 62 ‘ahibitB-6) Goals and objectivesesson from unwarranted of unreasonable Use of : vfs restraint practictmt are festraint or seclusion. |, comin ain ‘Behibit C-1, The ; b Restrant/Behavioral Management Skis Review of Patient #4's medial record revealed, | | Checklist was completed after succesful | he tachty edt the patent on 06/28/18, wh | | CRSpletin ofthe pecticum, ands tagnoses which included Organie Brain \ anaes next C2, Attendance Saadrome, Alzheimers Disease ané Dementia | Sra ates foc the pratima Syncgome, Meera Disturbances. Review of | | she wt ee Resa Tre ecord rovealed Patient #4 was referred to the | Se earn | facilly from the long term care facil inwhich | | improvement processes 1 [Xe resided for evaluation of his/her ‘combative| used to appropriately evaluate the use aera which had become violent at times, ang restraint and/or secasion with a forns 8 for frequent falls. Record review revealed Patient| prevention, reduction, and improved || 14 weet admitted tothe tacts geriatric Mien outcomes. The coletionoftNle 1 oyehiattc (gero-psych) behavior unit afler IRS | Gata started on August 13,2015, 18 1 ease pvatuation inthe emergency room (ER) | a jowed daily onal patients in eaten, Continued record review reveaiad Patient #4 fand a monthly summary 7ePO# iS ‘exhibited aggressive behiaviors at times. \ | submitted to our performance ' | Gimprovement departaent ‘This will _ Review on 07/1775, of he fac video \ arnatinue to be reviewed and reported to Teoording for the gero-psych behavior ni } the Quality Coordinating Counc i Tevoated Patient #4 was siting in a gerechaie | | monthly, by the BE morse manager or 1 (specialized tediner inthe uns day oom te the Vice President of Nursing. The fn 07/04/16 at 3:00 PM unt 16 AN | festraint performance improvement w Or o2/15., Review of the video at 9:20 PM sein Peete on ee « Povoatad two (2) staff, Ceres Nursing Assistant | approved resins with ompP TT | RN pialy Footed inthe units day room, Tet | documentations oulned in ACUN’ i notiyprcatve trarpeulio water bags were Used {_ Ro Retsint and Secs policy. MATE FORM “ auyatt Hteantouatonseet 1PRINTED: 0810802015 ORM APPROVED ice of Inspector General a STATEMENT OF OFFIGENOES Fay FROVERSUPRIETIGLIN Fa TPE CONSTRUCTION Say OnTE SURVEY SMEthoF CORRECTION FeowoenseMuMse® | a BULONG: COMPLETED c _so0ar2, __ lene 712312018, Nave OF PROMDER OR SUPPLIER TrREET ADDRESS, CTY. STATE, Z CODE 4 MEDICAL VILLAGE DRIVE TL ST ELIZABETH MEDICAL CENTER e000, KY A047 pao Span STATEMENT OF OETORNOIS FROOERS PLAN OF CORRECTION a BD eAcHDeROENC SE seo oy FULL ee Stornecrive ACHION SHOULD EE colbuene He AOS Sse DENTIFYNG HEOATION EAN eeeeceD fo THEAPPROPRNTE | ‘owe DEFICIENCY 820: Continued From page 11 as an actly diversion, a sensory device for | patients 0 "lay with ang amuse, themselves. | pated tye trerapeutc water bags cones Fe tent colored plastic fish inside and whet the Gage were touched the fish moved ‘around. RN! Pam ey he did not know the weight of (Ne \ (erpeutc water bags or which staf member | provided the water bags for Patent 44, Ho stated | Froeembered secing Patient #4 pang with - the therapeutic water Bags Newent id not the My gezing the water bags paced 9 19? ‘rine | pallens tower legs with tho tbe pulled over top | mae er blatoral ower exreriies, AU Signed he did not consider the table Cot Patient tora ower legs and the Wo (2) Chats tee oad ageirot the pack ofthe ger-chol St \ went Further intrviow revealed Yer vit | laff used a restraint for a patient the Physician \ i [was always called, bul Re ha 08 ‘called the een regaring Patent #42 the palent WS notin a restraint Intent pated in aint fs cave uth we ang Shi, 3:00 PM fo 11:00 PMO th ota, reveated she remembered S000 Seta “playing” wih a beach ball and Patent rater bags. Per nferiew che oe i herape ror placing the torapeutc voter > ao eae lower extremes or sce Ne ver Pate" no paliont’ clove Over TeGS; | tobe cg Yo CHA 2, she aso dd 00052 \ Acco wo ) chai atthe bark hPa, (Bigs gericna. Sho alaed she 08 recall Has got rao wth dong a adr s0an of | ass eA ond taleting Patent #4, Furnes | of \ | Interview with CNA #2 0n O7HHGI45 af 3:25PM, | | interview revealed however, restraints were out Intervet practi, and nurses abianed tne | restraint order ‘Tate FORM won | ee20 Tt ne associates sil receive ations) heaton through Mosby's Sls lb online ee usesTiearning abs. See New Tite Ghecist, Mosby's Skills orientation athine in Exhibit Fa. New hire | orientation competency shect revisions Fave been updated to ensue focus O° | reviewingal patents for approved reataint with supporting documen = | fou nNsand Cerca Asians, Exh \ p-2and F-3) Ongoing Behavioral Health | competencies for RNS ‘exhibit G-1) and sss 1 am Petassstant (ExBsbit G-2) were ceo on Aust 5, 2015 with at rere focus on restcaits. 815/18 4g, The Resteint Educational plan » sereviewed and revised on August S| ae vernal new he esningand | \ seing ana and spell SPECS ering wth elated objectives omen a eeparces defined See Exh HL DF tia incase of estraint education It all | oes of education. eat teantton sneet 12:Office of inspector Genta “STATEMENTOF DEFICIENCIES —[ OC) ‘AND PLAN OF CORRECTION 400272 PROVDETUSUPPLIERICLTA IBeNTIPCATION NUMBER: TA MITE CONSTRUCTION ‘A BULONG: oe 8. v"No PRINTED: 08/06/2018 ‘FORM APPROVED ra) are SURVEY COMPLETED c 7/23/2018 [NAME OF PROVIDEROR SUPPLIER. ST ELIZABETH MEDICAL CENTER TONIIARY STATENENT OF DEFICIENGIES (GACH DEFICIENGY MUST BE PRECEDED BY AE Rteay om isc DENTIFYING NFORWATE oa | rer TAS 820, Continued From page 12 Interview with Nurse (APRN) 07/2/14 at 10:55 Al for the gero-psych unit on \M, revealed she was ware of any nursing staff calling to request an | Sider for restraints for Patient #4 during patients current admission. The APRN stated Pationt #4 had been admitted to the gero behavior unit for Dementia and Behavioral Issues | and the meal saff were assessing the health status and re-a either interviow reveaiod when a pation psych unit was placed in a rostvint a hou Pejchiatst had to do ahead to toe asses covery shift during the restraint Interview with the Unit Manager (UM) of the FROMDERS PLAN OF CORRECTION. eo) POO” eqGt pbFIGNEY UST BE PRECEDED BY FLAL REE (CORUORRECTINEAGTIONSHOULOBE ° cOMEETE REE EER ATORY OF LSC ENTIFYNG INFORMATION) ne cfesenerenencenforeenvenorare ONE £830" ued Fr T Pago | Attendance sheets, with dates for practicum, oo ae aed if Jreavalable in Exhibit C-3. Restraint sans facility hetshe resided in, and was sent to the | Peformance inaprovernent processes reused facllitys emergency room (ER) for evaluation, | | to appropriately evaluate the use of restraint * Record review reveated Patient #4 was admied | andlor seclusion with a focus on prevention, tthe fact’ goa perce (gero-psyeh) | ‘eiuetion, and improved patient comes. ;ehaviorat unit era ‘The eollection ofthis dat started on August | Review of the facilly’s video on 07/17/46, of the ! 13,2015, is reviewed dally on all patent Feepeyen behavioral unk, on 07/01/16 touch | restraints, and a monthly summary report 5 Serpde veveaied al 9:20PM, CNA and ‘Submitted to our performance improvement another unidentified CNA were observed to i department. This willbe reviewed and { wedge two (2) chairs behind Patient #4's reported to the Quality Coordinating Council geri-chair and the door frame which prevented | | bimonthly, by the BEL murse manager or the the patient from reclining the back of the chai Vice President of Nursing. This restraint: ‘The video rovealed staff were also observed fo | performance improvement wil continue tobe | position a table over Pationt f4’s bilateral lower Pétlected on all patients in restraints fo ensure fegs and lower abdomen which prevented the | | Compliance with all requirements ofthe _ any ofthe patient to feely move hisyher lower ACLIN-R-03 Restraint and/or Seclusion ‘extremilies, Per the facility's Policy, a restraint | | policy. See Restraint performance ; was any device which provented free movement " Fmprovernent summary and action plan | of a patient's body and which the patient could nt! | template in Exhibit D+ easily remove. Continued review of the video | fevealed Patient #4 remained siting up in the | eae Geri-chair wilh the chairs wedged behind Wand 5.__ ABIL) focased Pe ens ae | the table positioned over his/her lower | improvement project was developer 1 ensure textremilis. The video revealed Pationt #4 was | appropriate restaintulization, BEY able fo move hishher upper body, however, was | eee (consisting of the unit manager, able stnved to be ablo to move his/her bilaterab charge nes and nesing sit upervion) ; lower extremities. Further review revealed | | will review all patients on the unit each shift | approximately eight (8) hours later when CNA #7 Tor proper resraiat utilization and supportive | Feported to work, the CNA and Registered Nurse | documentation as per policy. ffan {RN} #4 attompted to move Patient #4's gork-chat | snappropriate restraint practice is observed with dificulty, In addition, Patient #4's gork-chair | | during rounding/ observations, the situation was wheeled out of the video camera's view. | will e immediately corrected to ensure ! | | patient safety and then reported up the chain * nterviews, on 07/21/15 at 10:35 AM, with RN 4, | | Brcommand othe Vice President of Narsing { who worked the night shifl, 11:00 PM on \ | Ifa deficient resteaint practice is observed, the; 7101/15 to 7:00 AM on 07/02/15, revealed she | | situation wil be reported to Cabinet of Health | recalled Patint #4 siting ina reciningchaitin | | kat aye err "ACLIN-A-O1. the day room of the unt. RN #4 stated Patient | Gani A-2) #a's chale was against awall and a tablehad | : TATE FORM o ayant Afconiuatensest 186459PRINTED: 08/06/2015 FORM APPROVED Office of Inspector Genoral Oe Ot ee ENCES [Or PROWGERGURrLERCLA | OWMUIES SoRsTAGTION ay OATE SURVEY SND PLAWOF CORRECTION Petreanon NuMBER — | ayLDNG: COMPLETED c Ao0272 B.wing a 7/23/2018 TAME OF PROMIOE OR SUPPLIER [STREET ADDRESS, FY. STATE, ZIPCODE ST ELIZABETH MEDICAL CENTER TN at tl om “SINIARY STRTENENT OF DEFICIENCIES oi PROMDERS PLANO CORRECTION 3, GN eqGH DEFICIENCY HUST OF PRECLOED EY HUN Pree Ce UO RREGHTIEAGTION SHOULDBE | COREIETE REE | SESULATORY OR (SC IDENTIFYING INFORMATION Tae clsSineremeen one arora ‘ale CIENCY) L 1 Ee 830! Continued From page 1° 830 Tring the performance improvement ansns Soredmipe ree eae tend up to histher mid-abdominal area, She | {ecoctates will be removed from duty and any _ lated al 5:00 AM on 07/02/15, she was getting | irmproper use of restraints wil be immediately eady to toilet Patient #4 with the assistance of | corrected. Reporting ofthe iste will be bther staff; however, when they pulled on the | | accomplished via policy ACLIN-A-O1, Any patient's chal they fll resistance. Continued eeclved associates wil be counseled through _ Interview reves other sta helped herby \ | the hospital’ progressive disciplinary process removing the two (2) chairs wedged against | Und, provided they are not terminated will be Patient #4's chair back and then they wore able 0) jae Rrowed on restrain practices wi Slowly pul the patient's chair from under the : table. Further interviow roveated she observed subsequent esting as prevent desea 008 + two (2) ofthe unil’s therapeutic water bags iying [tha retin praca of Prone {we (ot ain’ war 99s, and Wafer 108 Application. (Exhibit C-1) Our goal with the om top ot ore the water bags had been. | + eased study willbe to ensure that patients wil } pat be restrained wing restraints not sted i -tnterviow, on 07/21/16 at 2:00 PM, with ONA# 7, | | the hospital policy, or without proper | Who had arrived for work the morning of O7/02/45 ' documentation. The performance wi5.00 Ald, revealed Patient #4 was siting in| Smmpeovementstady will continue unt there «ining chair when she arrived for work which vaateon- week period without any inappropriate had been placed against the wall in the units veatraints being used on the BHT unit, ARer the atv. She stated there was aso 2 fble “Sateen week period without inappropriate front of Patient #a's chair over his/her legs and se Metng used the fait wil contin to hairs bebind the redline’s back. Per interview, | orm observation fr sb oath to ese ithe nurse wanted to (ail! Pationt #4 and ae ace of sfe practices bythe BET Mtguosted hor assistance, so they pulled on the | complies pedormance improvement | patents reining char, bul mat resicance, CNA ae Chel in Exit E-. See WF stated it was hord to pull Palient #4's recliner aeration Chee een uray sheet ‘ul from under the table. She reported however, + aKa a Ssetaik Pees they dx get the reciing chair out from under the | eee fn fable and then she and the nurse ‘observed two performance improvement Proctty 1 | (2) therapeutic water bags lying on top of Patient | | ‘nursing leadership (consisting of the unit 1 eergwer legs. Further interview revealed RN #4 ‘manager, charge mses, and aursing sift | tapers) i perform a monty focused | | \ i 1 | Femoved the therapeutic water bags from Patient + H's legs, and there wore some red aroas where study utilizing the existing performance the bags had been. improvement plan and form, capturing 20 obgervations per month. ‘This will continue to be reviewed and reported to the Quality ‘Coordinating Council bimonthly, by the BH nurse manager or the Vice President of Nursing. | interview, on 07/18/16 at 3:40 PM, with RN #1, revealed he was Patient #4's primary care nurse ‘on the 3:00 PM to 11:00. PM on 07/01/15. RN #41 stated he remembered Patient #4 being in @ | | \ \ | TATE FORM we avant eontuatin eest 170119PRINTED: 08/06/2016 FORM APPROVED Office of Inspector General ~ [atarevent or percencies [on PRowbene ye “Bia) MULTIPLE CONSTRUCTION [3 OATE SURVEY SND LAN OF CORRECTION Peemcanon UNGER | gULONG: 7 ‘couriereD c ___ 190272 es 07/23/2015 NAME OF PROVIDER OR SUPPLIER. ‘STREET ADORESS. CHTY STATE, 2P CODE 4 MEDICAL VILLAGE DRIVE ST ELIZABETH MEDICAL CENTER EDGEWOOD, KY 41017 aio “pans STATEMENT OF BEFICIENGIES o FROMDERS FLAN OF CORRECTION 2 OR Geach DERCIENGY MUST RE PRECEDED EY FUN, vee | _(EACHCORRECTNEAGTION SHOUD EE | C°RTETE REE Ee tATOR OR USC IDENTIFLING NFORKATION) ae oAtitireneiceororme errorete | ONE 830° Continued From page 17 €630 | 4 Newhirecorientation, educational | g/13/15 reclining chai which had a table placed over the fesson plans with goals and objectives were pallents lower extremes. RN# stated he did | reviewed and revised on August 13,2015, t0 pot consider the table over Patient #4’s bilateral | | ence hatincteased emphasis placed ot fogs and the two (2) chairs wedged behind the | | She assessment of all patients for approved 1easning chair as restraints which restricted the | | rent th sappotg docunttion a Tnovement of the patient's bilateral tower legs. | eam ACLIN.R-03 Restraint and He staiod he was unaware ofthe tnerapoulle | Seclusion policy. BH nev aeociates wil water hags being placed over Patient fe | | peceive ational education through bilateral lower extremities however, Continued Se re calecemuveteaiog | {interview revealed if staff used a restraint 2 \ | Most ven Tce Checklist, Mosby's Sls Physician's Order was obtained after Physician | | lbs. See en nein Exhibit FL peat Fotiication. RN #1 stated however, he did rot, | | rienttion outing in Fahibit F-1- Ne Tontact the Physician on tho evening of 07/01/15, | oriemtation competency ee revisions have Decause Patient #4 was not ina restraint. Even | been updated to ensure focus on reviewing though the Policy defined a restraint as any ' | all patients for approved restraints with device which restricted the ability of a patient to \ supporting documentation for RNs and freely move his/her body and which the patient | erica Assistants. (Exhibits F-2 and F-3) | could not easily remove, and video review \ ' «oleate Patient was unable to ely move | | 2. ongingattcompancs rR gys | pisiher lower extremitos. \ {exhiic G3) and Cercaasitan Exhibit | | G2) were revised on August 5, 2015, with 1 | toterview, on 07/23/14 at 10:55 AM, with the increased focus on restraints. APRN for the gero-psych behavioral unit, { | fovealed ifa patient on a psychiatric unit was | f.TheRestaint Bdocatonal plan wal | gifts placed in a restraint @ house Psychiatrist had to patient remained in the restraint. She slated she | Go.a head to toe assessment every shit while the | i | | was not aware of any nursing staff calling to request an order for restraint use for Patient #4 [since ne ‘patient's admission to the faciity. " Interview with the Unit Manager (UM) of the SANs, rovealed if a restraint was used staff were to | obtain a Physician's Order. She stated therapeutic water bags were a warm water (gero-psych behavioral unit on 07/28/18 at £0:00 | | \ sensory activity for use with patients who had | Dementia, Tho UM stated the therapeutic water | bags shoutd not have been placed over Patient [bags shou po iron atae over en ot ie | TATE FORM | Sneed and revised on August 52015, for | inion ‘ongoing anal aorta spect aiing with rated objectives, content): ‘and resouirces defined. ‘See Exhibit H-1 for plan inclusive of | eScain education inal phases of education, ouvert Acontwaten chest 18018PRINTED: 08/06/2016 FORM APPROVED Office of inspector General en ES SSPRIENCES | 0a) PROVOERSUPPLIERIGLIA | O2IMULTIPLE CONSTRUCTION aay oare SURVEY SD PLAN OF CORRECTION Geuincarounoneee |, oyna oneieteD c aaa 00272 8 WING a | gnasiz018 NAME OF PROVIDER OF SUPPLIER ‘STREET ADDRESS, OY, STATE, 21° CODE 4 MEDICAL VILLAGE DRIVE ST ELIZABETH MEDICAL CENTER ee EDGEWOOD, KY 41017 or) Sunnie STATE OF DEMGINGES © PROUBERS PLAN OF CORRECTION m7 FO eqcitObricNeY MUST RE PRECEDED BY FULL rere (RMCORRECTIVEACTIONSHOULD BE COMPLETE EE eR uaTOY OF (90 IDENTIFYING NFORUATION) Tas AeNeenexceo rote arprormare | ONE DEFICIENCM £830 patient's legs restricting TATE FORM 830{ Continued From page 18 \ hisiher movement. | 1 { erat eomtnuaton sheet 19019