DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
361514 A. BUILDING __________
B. WING ______________ 		04/13/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
OHIOHEALTH HOSPICE 800 MCCONNELL DRIVE, COLUMBUS, OH, 43214
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0719      
32059 Based on medical record review, staff interview, and policy review, it was determined the facility failed to ensure patients were free from restraints by raising all four bed side rails on patient's beds per the fall prevention policy, prior to identifying if this was the least restrictive intervention. This affected two (#1 and #2) of three patients reviewed and has the potential to affect all patient's admitted to the inpatient hospice facility. The systemic effect of these practices resulted in the facility's inability to ensure patient's were free from restraint and/or seclusion. The facility in center census was 18 patients. See citation at L737.
L0737      
32059 Based on medical record review, staff interview, and policy review, it was determined the facility failed to ensure patients were free from restraints by raising all four bed side rails on patient's beds per the fall prevention policy, prior to identifying if this was the least restrictive intervention. This affected two (#1 and #2) of three patients reviewed and has the potential to affect all patient's admitted to the inpatient hospice facility. The facility in center census was 18 patients. Findings include: 1. Review of the medical record for Patient #1 revealed the patient was admitted to the facility for a respite stay on 03/29/21 and discharged on 04/03/21. Review of the daily/hourly safety rounds documentation noted all four side rails were raised on the patient's bed throughout the entire stay. The medical record lacked documentation of other less restrictive options available to the patient thus preventing freedom of movement from the bed. 2. Review of the medical record for Patient #2 revealed an admission date of 03/06/21. The The nurse note on 03/07/21 at 1:23 PM revealed the patient was confused with hallucinations and trying to get out of bed. The nurse note on 03/08/21 at 12:29 PM documented Patient #2 was continuing to try to get out of bed. Review of the safety checks from admission revealed all four side rails were raised on Patient #2's bed. The medical record lacked documentation of other less restrictive options available to the patient thus preventing freedom of movement from the bed. Interview on 04/13/21 at 12:37 PM Staff F confirmed the safety checks noted all four side rails were raised. Review of the facility policy titled "Fall Prevention," Number OH.POL.P-100.003, effective date 12/20/2019, indicated all hospital associates will engage in fall prevention activities for the purpose of reducing the occurrence and/or severity of patient falls. A fall is defined as any event which results in the patient or a body part of a patient coming to rest inadvertently on the ground or other surface lower than the patient. A sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface, on another person, or an object. An addendum to the policy noted all patients admitted to inpatient facility are considered to be at risk for a fall. Unless indicated by the physician every patient has side rails elevated. An interview with Staff E on 04/12/21 at 2:19 PM verified all patients admitted to the facility are considered a high fall risk. The beds are placed in low position, call light is in reach, and there is use of a bed alarm. The beds are never placed in a high position and/or with all four side rails up as that is considered a restraint. An interview was conducted with Staff A on 04/13/21 at 4:19 PM who reported the facility does not have a restraint policy as restraints are not utilized at the facility. Staff A indicated placing all patients in beds with all four side rails up at all times could pose a safety risk and be considered a restraint. Staff A stated the facility will re-evaluate the fall prevention policy.