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A 023 We respectfully request

that this item be removed from

the Statement of Deficiencies

because it is mistaken in its

statement concerning Missouri

State Law and exceeds the State

Survey Agency’s authority under

Missouri State Law. The

Missouri statute concerning theemployee disqualification list

(Section 660.315, RSMo) states

only that “[n]o person,

corporation, organization, or

association who received the

employee disqualification list

under subdivisions (1) to (5)

of subsection 11 of this

section shall knowingly employ

any person who is on the

employee disqualification

list.” The statute does not

state that the list must be

checked “no less than annually

and periodically on all

employees as long as the

employee is working at the

facility” as stated by the

State Survey Agency. Nor has

the State Survey Agency or

other Missouri state agency

promulgated a rule interpreting

Section 660.315 to establish

such a requirement.

Continued page 2

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In an effort to comply with the

surveyor interpretation,Human

Resources Department has

implemented a policy that

requires the department to

periodically check all current

employees against the state EDL.

This will be completed quarterly

by the HR Department. An EDL

audit was completed 1/24/2011.

The audit showed no current

employees were on the EDL. The

Chief Human Resources Officer is

responsible for the

implementation action.

Effect

2/15/2

To the extent that this

statement of the State Survey

Agency reflects its

interpretation of Section

660.315,Missouri State Law

prohibits the State Survey

agency from establishing such

requirement by interpretation

without going throughestablished statutory rulemaking

process. See Sections

536.010(6) and 536.021, RSMo.

In any event, University of

Missouri Healthcare is not

subject to the requirements of

Section 660.315 because it is

not one of the types of entities

identified in subdivisions (1)

to (5) of subsection 11 of

Section 660.315.

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A0143

A0144

A0154

The Plan of Correction for Tag

115, the Condition of Patient

Rights is addressed under the

individual tags related to the

condition.

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The hospital respectfully

disagrees with this finding. We

post the Patient Rights and

Responsibilities in public and

conspicuous places throughout

the inpatient and outpatient

facilities to provide this

information to patients and

visitors. In addition, all

inpatients are provided a

personal copy of the Patient

Rights and Responsibilities. In

the outpatient areas, the Rights

and Responsibilities are posted

at each registration desk. To

comply with the surveyor

interpretation, the hospital has

instituted a new process that

requires both inpatients and

outpatients to be provided

education on the Patient Rights

and Responsibilities.

Registration staff will present

and discuss with each patient a

summary of the Patient Rights

and Responsibilities. Each

patient will be offered a full

copy after the discussion.

Patients will then sign the

Conditions of Service Agreement

acknowledging that they were

provided the Patient Rights and

Responsibilities.

cont. a e 5

2/28/

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This documentation will then

become a part of the patient

registration record. The

Director of Patient Financial

Services in conjunction with the

Director of Clinical Operations

will be responsible for the

overall implementation of this

process.

Other important actions and

responsible parties include:

- Documenting that patients

received a copy and understood

their Rights and

Responsibilities.

Responsible party: Manager,

Registration; Clinic Managers

Training of Registration staff

will be completed by 2/25/2011.

Responsible parties: Revenue

Cycle Training Department with

overall responsibility by

Director of Financial Services

in conjunction with Director of

Clinical Operations.

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University of Missouri Health

Care has signs conspicuously

posted throughout the

facilities that inform patients

and visitors that the

organization utilizes closed

circuit cameras to monitor for

safety and security. Upon

entering the Emergency Room,

there is a sign in the

Registration area that states

the ER is being monitored by

closed circuit TV. The Sleep

Lab has for many years provided

education to all patients,both

verbally and in written pre-

procedural educational

documents, that the patient

will be video recorded as a

part of the procedure.

To comply with this most recent

interpretation of the

standards, the hospital has

placed signs informing the

patients in the Sleep Lab rooms

and the Trauma Room that these

areas are under surveillance.

Signs are provided for the

portable monitoring equipment

used for epilepsy monitoring of

patients in regular inpatient

rooms.

Continued page 7.

1/25/2

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Additional signs were placed

before the completion of the

survey and the surveyors were

made aware of this action before

they exited the hospital on

1/25/2011. In addition to the

additional signage, wording has

been added to the Conditions of

Service informing patients that

UMHC uses closed circuit

monitoring for safety and

security purposes. All patients

will be asked to validate by

their signatures that they are

aware persons entering these

facilities are being monitored

by closed circuit television for

their safety and security.

Responsible party: Manager of

Regulatory Affairs.

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curtains have been placed over

the windows of the doors in the

behavioral health pediatric unit.

Responsible party: MU Psychiatric

Center Director of Clinical

Operations

1/26/

A 143

The hospital respectfully

disagrees with this finding

because current policy already

does not allow patients to

change clothes in their rooms.

We would also like the record to

reflect that the bedroom doorwindows were initially installed

as a result of a past DHSS

survey that cited the facility

for not being able to observe

the patients while the patients

were in their rooms. In order to

comply with the most recent

standard interpretation,

See Page 11 for Tag A 144.

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The hospital would like the

record to reflect that these

observations were never cited by

DHSS surveyors in the past when

the facility was operated by the

state. UMHC took ownership of

this facility on July 1, 2009

from the Missouri State

Department of Mental Health. At

that time, UMHC informed all

state parties involved in the

transfer of ownership, including

the state legislature, that the

facility was in need of

significant renovation and

repair. The Missouri Legislature

approved the transfer and

provided funding to accomplish

the renovations. UMHC prepared

a work plan that outlines the

time line and the funding for

each repair. As an example, the

second floor unit is being

completely rebuilt and relocated

with the expected opening of the

new unit to take place in April

2011. The new unit will be a

state-of-the-art psychiatric

unit.

Cont. page 12

1/25/2

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While we are in process of these

renovations,the psychiatric

staff has an existing process

for screening each patient for

potential suicide risk and

providing the appropriate level

of monitoring. If a patient is

determined to be at risk for

suicide or destructive behavior,

the patient may be assigned an

escort and is monitored closely

at all times. As shared at the

time of survey, UMHC believes

our screening and monitoring

process has been effective at

preventing suicides, as

evidenced by a lack of suicide

attempts in the restrooms over

the past 15 years.

Since not all patients are at

risk for suicide or destructive

behavior, the hospital is

concerned that restricting

bathroom access and providing

constant visualization of all

patients utilizing the bathrooms

does not respect the patients’

rights to dignity and privacy.

However, we complied with the

surveyors' request to

immediately lock the bathrooms

and monitor patients while in

the bathroom until renovations

can be completed.

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Adult Inpatient Unit #2, 2

South

Women’s and Men’s Restrooms:

These restrooms are locked

until a patient requests to use

the restroom. Then the patient

is monitored by the staff. New

anti-ligature shower heads and

bathroom fixtures are being

installed. Once the

installation of the new

bathroom fixtures has takenplace, the restroom will be

open to patients.

Continued on page 14

We initiated renovation of these

restrooms as follows:

Adult Unit #1, 3South

Women’s Restroom: The remodel as

requested by the surveyors'

interpretation was completed

1/25/11.

Men’s Restroom: The remodel is

completed pending a safety

retrofit of plumbing fixtures.

Restroom is locked until a

patient makes a request and then

patient’s usage is restricted by

constant staff monitoring.

Expected completion date is

2/26/11.

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2. The hospital respectfully

disagrees with these

observations. The nurse

assigned to these patients

states that she could see the

access ports of two of thepatients in question. One

patient had the access port in

the groin area and that patient

was allowed to cover himself

enough to ensure his privacy but

the nurse could see the access

port from her vantage point.

The second patient's access port

was also visible to the nurse

from her vantage point.

The third patient was cold andhad just pulled his blanket up

above his access port.

Cont. page 15

This unit is scheduled to be

relocated to a newly remodeled,

state-of-the-art unit in April

2011. Responsible party: MU

Psychiatric Center Director of

Clinical Operations.

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The surveyor made the

observations from the doorway of

the unit and was not in the same

position as the nurse to

visualize the access ports in

question.

In order to comply with the

finding, however, the hospital

has implemented the following

plan.

The policy and procedure for

initiation of dialysis has been

amended to reflect the current

practice of ensuring visibility

of access ports at all times

during hemodialysis treatment.

The need to have hemodialysis

access sites visible to staff at

all times has been reinforced at

staff meetings.

Patients will be instructed at

initiation of treatment that

sites must be visible to staff

at all times for patient safety.

Monitoring and audits will be

performed in the hemodialysis

unit to verify compliance with

visibility of sites.

The Dialysis Manager will be

responsible for enforcing and

monitoring these practices.

2/24/

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2/24/

University of Missouri Health

Care’s existing emergency plan

for horizontal and vertical

evacuation has been augmented

with the development of a unit-

specific plan for the NICU at

Women’s and Children’s Hospital.

NICU staff assembled amultidisciplinary team,

including clinical staff,

administration and Emergency

Management leadership, to

develop and document the

emergency evacuation process.

The plan clarifies staff

responsibilities, details the

necessary equipment and

supplies. The plan calls for

all babies to be evacuated inkeeping with national standards

that triage the evacuation order

based on immediate danger,

patient stability and level of

acuity. NICU staff will be

educated regarding the plan on

Feb. 22-24. The manager of the

NICU in conjunction with the

interim director of Support

Services are responsible for

implementing the plan. See

Attachment A.

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The hospital policy has been

revised so that handcuffs will

not be used on a patient unless

the patient’s behavior is

considered a criminal action

and the incident will be

reported to the appropriate law

enforcement agency. Non-metalescort devices will be used in

areas where other types of

restraints cannot be used.

These escort devices will only

be used in accordance with a

physician's order. All

hospital security officers have

been educated to the

requirements of the new policy.

The Manager of Hospital

Security will be responsible

for the implementation and

monitoring of these actions.

2/9/2

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See page 21 for A 168.

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The hospital has amended the

restraint policy to reflect that

when manual holds are initiated

by a staff member a physician

order is to be obtained. The

revised policy now states the

following;

10. If a patient is placed in a

manual hold, an order for this

type of restraint is required.

These changes were approved by

the Executive Committee of the

Medical Staff on 2/21/11 and

will be distributed to the

medical staff. Hospital staff

will be informed of these

amendments through internal

communications.

The Coordinator of ProfessionalNursing, the Chief of Staff and

Chief Medical Officer will be

responsible for implementing

these changes.

3/10/1

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A176 UMHC has amended the

restraint policies to reflect

the following changes to

physician education on the use

of restraints.

14. Resident physicians will

receive education on the use

and application of restraints

and seclusion as part of the

resident physicians new hire

orientation.

15. Credentialed physicians

will complete education related

to restraint and seclusion upon

initial credentialing and

recredentialing.

All currently credentialed

medical staff members will

receive individual copies of

the restraint policies and a

educational summary of their

responsibilities in the use of

restraints.

3/10/

The Chief of Staff and Chief

Medical Officer will be

responsible for implementation

of this action.

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3/11

A267

Language Services is responsible

for the ongoing process of

monitoring, evaluating and

improving quality of care and

patient safety for the patients

we serve. Our two focus areas

for improving our services are

1) determine the specific

language needs of our patient

population and 2) educate staff

how to identify Limited English

Proficiency (LEP) and Deaf/Hard

of Hearing (DHH) patients and

how to access services to meet

patient needs. We will report

to the MUHC Quality and Patient

Safety Committee twice yearly

with performance data based on

manager evaluations in clinical

areas utilizing Language

Services.

Cont. page 26

3/11

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The damaged doors were repaired

or replaced by maintenance

staff on 1/25/11.

The Associate Director of

Facilities and Building

Operations is responsible for

implementing and monitoring ofthis project.

1/25/

Manager evaluations will assess

whether Language Services 1)

provides timely/efficient/

accurate services and 2)

responds to concerns in an

effective and timely manner.

Based on these results,

additional expectations for

performance improvement and

reporting will be defined.

The Director of Patient Family

Centered Care will be

responsible for the

implementation of this action.

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A 749

The hospital will respond to

this finding by increasededucation, monitoring and

accountability for failure to

enforce or comply with hand

hygiene standards.

1.Infection Control has

developed and deployed new

screen savers on patient care

computers that emphasize hand

hygiene between glove changes.

IC staff members have provided

education to staff in the MU

Psychiatric Center in regard to

medication passes. IC will

provide additional education to

the Food Service staff on proper

hand hygiene during food

handling. This also includes

proper utilization of hair and

beard coverings.

IC will also train managers and

supervisors in observation

techniques.

Cont. page 28

3/10/

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2. In addition to monitoring in

the ICUs and ED, the hospital

will increase monitoring to

include all departments with

patient contact. Managers and

Supervisors will round in their

areas daily.

• A Hand Hygiene Monitoring

Tool has been developed to

record hand hygiene

observations. Immediate

feedback will be given to staff

at the time of observation.

• Observations of other staff

will be sent to the appropriate

manager.

Completed forms will be sent to

Infection Control. Infection

Control will review the data

and send collated information

back to all departments.

Outcomes will be shared with

senior leadership and medical

staff and posted in each area

for staff to review.

3.Any employee with multiple

infractions will be counseled

by his/her manager and failure

to improve will result in

progressive discipline.

Responsible party: Chief

Operating Officer in

conjunction with Manager of

Infection Control.

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