CMS immediate jeopardy follows possible restraint, seclusion issues

Briefings on Accreditation and Quality, November 1, 2017

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This September, a Missouri hospital found out the hard way that when not addressed quickly, restraint and seclusion deficiencies can threaten a hospital’s ability to remain open, as well as who keeps their job.

CMS twice this year ruled that Mercy Hospital Springfield was putting patients in immediate jeopardy for what it deemed abusive incidents, including some involving restraint and seclusion. This included one incident where a nurse pinned a violent patient to the floor and didn't report it.

The agency gave the hospital until September 22 to come into compliance or lose Medicare certification. As of September 12, “CMS has not received an acceptable Plan of Correction,” said CMS spokesperson Julie Brookhart, in an email from the agency’s Kansas City Regional Office.

At least 12 hospital staffers have already been dismissed as a result, with a hospital spokesperson saying their behavior in “highly tense situations” was deemed inadequate. A new team of interim hospital leadership has been put into place.

Restraint and seclusion

CMS defines a restraint as "any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely" or "a drug or medication when it is used as a restriction to manage the patient's be-havior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition."

There are limited circumstances where providers can use restraints and seclusion. CMS says that they should only be used to ensure the immediate physical safety of the patient, staff members, or others, and should be discontinued as soon as possible. Moreover, the agency states that restraints and seclusion should only be used when less restrictive alternatives are ineffective to protect the safety of patients or others.

A single restraint and seclusion violation can be enough to trigger immediate jeopardy, since the rating only requires that one individual be put at risk. CMS also considers the potential for harm and psychological harm are also considered as bad as physical harm.

Hospital heightens training

In response to media coverage of the immediate jeopardy ruling and the staff dismissals, Mercy Hospital Springfield spokesperson Sonya Kullmann said several changes at the hospital, including increased staff training, were part of an effort to provide a safe care environment—which she noted is made increasingly difficult by the overall rise in levels of drug addiction and mental health issues.

Brent Hubbard, MBA, FACHE, the hospital’s chief operating officer, told staff in a statement: “As Mercy co-workers, we are called to treat every individual with dignity and respect even in difficult situations that may pose physical risks for ourselves. The actions we have taken, and the new level of training we are implementing, are critical to ensuring that our co-workers have the education and support necessary to ensure the safety and wellbeing of everyone.”

An immediate jeopardy finding by CMS requires a quick response by hospital leadership to prevent the loss of Medicare funding, which can force a hospital to close, say hospital accreditation experts.

The response must be clear and address specific issues that lead to the immediate jeopardy ruling, notes Jennifer Cowel, a former Joint Commission director of service operations and now president of Patton Healthcare Consulting in Naperville, Illinois.

Under Joint Commission standards, the frequency of restraint and seclusion training is up to each hospital, says Cowel. Both CMS and The Joint Commission require training upon orientation and ongoing. For The Joint Commission, it's implied that the training must be at least annual, she says.

First incident reported in January

This is the second time this year that Mercy Hospital has faced immediate jeopardy after a CMS investigation. The first investigation was in early January.

At that time, a CMS surveyor found significant violations under CoP 42 CFR § 482.13, Patient’s Rights, related to incidents in the hospital’s Behavioral Health Unit (BHU), according to an inspection summary report published on the Association of Health Care Journalists’ site.

One incident involved a patient diagnosed with schizoaffective disorder admitted just three days before the inspection, according to the January inspection report. The patient was admitted to the BHU shortly before 5 a.m. and quickly was in a confrontation with a registered nurse. As is standard practice, the public report did not include names of staff or patients, to protect privacy.

The patient screamed and spat on the nurse’s chest, according to the report, which cited an audiovisual recording of the encounter. “Don’t ever spit on me again,” the nurse said, moving forward toward the patient.

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