Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 530015 (X3) Date Survey Completed 07/13/2017
Name of Provider or Supplier St Johns Medical Center Street Address, City, State 625 East Broadway, Jackson, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0166 PATIENT RIGHTS: RESTRAINT OR SECLUSION
CFR(s): 482.13(e)(4)(i)

The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient's plan of care.


This STANDARD is not met as evidenced by:
Based on medical record review and staff interview, the facility failed to modify the care plan for 1 of 2 patients (#14) with restraints or seclusion. The findings were: Review of the medical record showed patient #14 utilized soft wrist restraints on 6/20/17 and 6/21/17 due to being intubated and attempts to self-extubate. Review of the care plan showed restraint use was not addressed. During review of the medical record on 7/13/17 at 10:15 AM the Quality and Accreditation Specialist confirmed the care plan did not address restraints.