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)
A0171 PATIENT RIGHTS: RESTRAINT OR SECLUSION
CFR(s): 482.13(e)(8)

Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age;


This STANDARD is not met as evidenced by:
Based on medical record review and staff interview, the facility failed to ensure orders for seclusion were renewed within 4 hours for 1 of 1 adult patients (#16) who was in seclusion to manage self-destructive behavior. The findings were: Review of the medical record showed patient #16 had suicidal ideations and the physician wrote an order for a Title 25 hold and locked seclusion on 6/29/17 at 3:46 AM. The order was renewed on 6/29/17 at 7:59 AM (4 hours 13 minutes). The next renewal order was on 6/29/17 at 11:07 AM, but the following renewal was not until 4:13 PM (5 hours 6 minutes). The next renewal was 6/29/17 at 9:19 PM (5 hours 6 minutes). The next renewal was 6/29/17 at 11:42 PM, but the next renewal was not until 6/30/17 at 4:22 AM (4 hours 40 minutes). During an interview on 7/13/17 at 11:30 AM the associate director of nursing confirmed the renewal orders exceeded 4 hours. She stated the facility had identified that as a concern recently.