Survey found deficiencies with patients in restraints, fire safety issues at Mount Carmel St. Ann’s


COLUMBUS (WBNS) – A federal health agency’s in-depth survey of Mount Carmel St. Ann’s found patients were left in restraints without proper checks from nurses and that actual buildings had fire suppression issues that violated national fire safety codes.

These latest documents were reviewed by 10 Investigates.

This in-depth survey was completed by the Ohio Department of Health in mid-March.

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The inspectors were working on behalf of the Centers for Medicare and Medicaid Services.

It marks the third time health inspectors have conducted surveys on Mount Carmel Health System facilities since news of the patient overdose scandal broke in mid-January.

Previous surveys focused mostly on issues with Mount Carmel’s pharmaceutical services and examined how Dr. William Husel and other caregivers were able to access large doses of pain medications that were later administered to 35 patients over a period of four years. Husel was fired in December after an internal investigation. More than 30 current pharmacists, nurses and their supervisors were placed on leave.

CMS has threatened to pull Mount Carmel’s Medicare funding in wake of the scandal and the hospital has made a series of corrections in an effort to avoid that.

The most recent survey found that Mount Carmel St. Ann’s Hospital was not in compliance with Medicare standards related to the supervision of nursing care.

“Based on medical record review, policy review, and staff interview it was determined that the registered nurse failed to assess and monitor patients in non-violent restraints every two hours per policy. This affected three patients of three medical records reviewed with restraints. A total of 45 medical records were reviewed,” the report states.

The inspection report also noted that a policy revealed that a registered nurse is to assess and document at a minimum, every two hours for patients needs and responses. “This includes proper application, skin, circulation checks, numbness, tingling, respirations and readiness to discontinue restraint.”

A review of the medical record for patient #13 and the nursing flowsheets revealed the nurse failed to assess and document every two hours as per policy.

a). On 03/08/19 the medical record lacked a two hour check from 3:24 AM through 7:56 AM

b). On 03/08/19 the medical record lacked a two hour check from 1:29 PM through 5:11 PM

c). On 03/10/19 the medical record lacked a two hour check from 9:30 AM through 12:28 PM

d). On 03/11/19 the medical record lacked a two check from 11:38 PM through 2:00 AM

A review of two other medical records for patients #14 and #15 found that they two did not have two-hour checks while placed in non-violent restraints.

This more robust survey of Mount Carmel St. Ann’s also found problems with the physical environment – including issues that did not comply with national fire safety standards.

“Based on observation, interview and document review, the facility failed to protect penetrations in barrier between it and other building occupants, to have paths of egress free of obstructions …”

Among the findings: Mount Carmel St. Ann’s failed to have an exit corridor free of obstructions. Multiple boxes of air filters (at least 11 boxes) were placed near the exit stair on the northwest side of the building.

“This finding had the potential to affect all patients receiving services at the facility,” the report noted.

Another finding noted that there was no visible exit sign near the south and west of neonatal intensive care unit, which was obscured by multiple curtains for patient care.

The facility also failed to inspect and test all components of the fire alarm system.

Other fire suppression issues noted included a lack of barriers in some areas and concerns about fire alarms and doors that would not latch.

Inspectors also noted that the facility also failed to have policies and procedures that addressed the disposal of sewage and waste of patients and staff. In an interview with inspectors, two staff members said that they would use an incinerator that is on campus to take care of waste but they could not show this in policy. Other staffers said that there have been places to get rid of the incinerator.

Mount Carmel has issued a plan of correction to address these deficiencies.

As it relates to the patients left in restraints, the hospital said it reviewed its policy and determined that it adequately addresses the requirements for restraint assessment every two hours. The hospital has also developed internal tools and educated nurses on using non-violent restraints.

The hospital also updated its facility service policy to address the disposal of patient waste and posted it to the intranet for easy access for Mount Carmel employees.

The hospital also said it plans to remove air filters stored in a staircase area at Mount Carmel St. Ann’s and conduct monthly checks to ensure the stairwells were not being used for storage.

The hospital also notes it plans to complete a facility-wide inspection of all firewalls to address fire suppression concerns.

Mount Carmel's statement from Ed Lamb, MCHS President & CEO, regarding CMS acceptance of the corrective action plan for Mount Carmel St. Ann's:

"The Centers for Medicare and Medicaid Services (CMS) has accepted Mount Carmel St. Ann's plan of correction to address areas—many of which relate to the physical environment of the facilities—they found needed improvement during their last visit.

"We have completed 100 percent of the corrective actions detailed in that plan. We anticipate CMS to return to our hospitals for a follow-up visit to assess and confirm that all appropriate actions are complete and effective. We will continue to cooperate fully with them and the Ohio Department of Health, and expect to hear about Mount Carmel West's plan of correction soon.

"Nothing changes in our ability to treat patients covered by Medicare or Medicaid. Our top priority remains providing safe, high-quality care to our patients, and we are confident that we have processes in place to do just that."

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