And now, I would like to introduce our speaker to get us started with Part 2. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility, Patient Safety, and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Reeds University, a Doctor of Just Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. And she is licensed to practice law in Colorado and in California. We thank you so much for being back here with us this morning. Laura, I invite you to get us started with Part 2. Okay. Thank you, Lindsay, and welcome, everyone. This section that we're going to be talking about is a very involved section within the manual, and that is the patient rights section. And it covers so many things. So we do have a lot of slides. Yes, you'll probably see 224 slides. I'm not covering all 224. There's multiple resources at the end. But this is a huge and very important section. It's probably the most often cited section for deficiencies that CMS issues against hospitals. So that's why it's a very important section, and it's separate from the culmination that we usually provide in these series where I've added things together. Our program is informational only. It is not meant to serve as providing legal advice nor establishing an attorney-client relationship. Rather, please consult with your in-house counsel, attorney, legal representative, whoever that happens to be, especially as it relates to issues specific to your hospital. Now, that doesn't mean I'm not willing to answer questions. I can only address them from how CMS would respond to that particular situation. For those of you who've been on these programs, we know that this is why we're doing this, why Georgia Hospital Association puts these on. And that's so you don't get the statement of deficiencies where they find you're not in compliance. And no facility or even provider wants to get notice that they've been terminated from the Medicare and Medicaid agreement. That is a huge financial hit for any facility or provider. And that's usually after some pretty egregious situations. And egregious meaning there are a lot of condition-level citations. There were probably injuries or potential injuries to patients because of those deficiencies. Or it could just simply be that the facility didn't allow the surveyors access into their hospital to do a survey. I just want to give you a few examples of some of the more common deficiencies I've found. Again, this is very important because patient rights is the largest section of the acute manual. There's over 78 pages to it. Now, surprisingly, there is no similar section in the critical access hospital manual other than visitation. That's the only place. Patient rights in a critical access are in the swing bed section. So the question becomes, okay, we don't have swing beds, do we have to do anything? And the answer is yes. If you have a critical access hospital in your system, you might want to have them listen to this program because you have to do something, in particular, restraints and seclusion. So here's just some examples of the deficiencies. They didn't resolve a grievance within a reasonable timeframe with a written letter back to the patient or to their representative, hey, this is what we found or what we did. They didn't adhere to the resolution of their grievance within the timeframe according to their policy. So they said, here's our policy, but they weren't following it. They didn't establish a timeframe for the response. They didn't provide the patient with written notice. And all of these are things we're going to cover. And then just a few more. They didn't make sure that we treated patients with dignity. They restricted diet of a patient. Suicide precautions, excuse me, the son committed suicide. They didn't have precautions for one-to-one. That is a typo. Forgive me on that. And then they didn't obtain interpreter services, and they didn't make sure they were protected. In other words, the video showed that a mental health technician kicked a patient in the chest during an altercation. That was on a video. And they didn't do anything to make sure, hey, maybe this isn't the person who should be working here or at least in behavioral health. So the manual we're covering today is hospitals, Appendix B. You have transmittals for those. That's when a new manual has come out, and you want to go to the quick one. Your last manual was updated in March, excuse me, April of last year. I am expecting there might be a new one coming for criticals, hopefully for you also because it's now 2025 and there have been some updates. What we're talking about today is you'll see here on, this is slide number nine, and that is the patient rights section, again, very large section. So let's go ahead and start. These are massive number of tags, starting with tag 115. We have to protect the patient rights. We also have to promote those rights. And this applies to all Medicare, Medicaid participating hospitals. And it's across the gamut of what type of hospital. By the way, it doesn't matter if the patient is on Medicare. We do this for all patients. It applies to all locations, inpatient, outpatient, if you're provider-based. Now, surprisingly, again, and I want to reiterate, this rule is not applicable to critical access hospitals, but they must do something to protect the rights of those patients. The standards include we have to give notice to patients on how they can exercise those rights. And that's the gamut of what those rights are, whether it's privacy, grievances, down to advanced directives. We're going to go through here during this program and talk about these. The restraint issues are almost 50 pages of standards, and that includes notification if a death occurs while a patient's in restraints and or seclusion. So on their grievance process, we first off have to make sure that the notice of rights is met, and that includes a way the patient understands, whether it's limited English proficiency or low health literacy. And that's why you have to have those policy and procedures to make sure patients get information on how they exercise those rights. We have to inform patients of what those rights are, and that's before we give care. And that could be something as simple as putting up an ED, putting up a registration, or even an OB, because patients sometimes go right from the front door up to OB. And we do this so we know that we're protecting and promoting those rights. We have to make sure they have the information on those rights. And it can be, if you're not going to put it up in the hallway or on a board somewhere, make sure it's on that registration form. It can be on the back of that form if you don't want to waste paper and kill trees. Put it on the back so they know what those rights are. I'm going to just digress here for a minute, and it's called the IAM notice, which stands for important notice, important message. And this is for Medicare. This goes to your Medicare patients. You have to give this within two days of admission, or at least an advance of discharge. And this really is good notice to certain observation patients, because what you're telling them, especially in observation, you're not inpatient yet. So you're still outpatient, and you need to know what's involved in that outpatient. I'm just going to talk briefly on Medicare Advantage notices. I usually don't get into billing. This is a separate topic, but just really quickly, because I get a lot of questions on it. Medicare Advantage, those are separate organizations, and they have to also provide their enrollees of a notice of non-coverage. That's Notice of Discharge of Medicare Rights, or NODMAR. This only when the beneficiary doesn't agree with the discharge decision, or when you as a hospital, if the Medicare Advantage has delegated its authority to make those discharge decisions. So that would go to you. So they would either send it off to the Medicare Advantage program or to you. It is not discharging the enrollee, but it no longer intends to cover the inpatient stay. So that's the difference with this one. You can go and stay in the hospital. We don't care. We're just not covering it if that's what you want to do. So back to our regulation. Take steps to determine who is the representative. The representative is that person who works with the patient to act on their behalf. They can step into their shoes if need be. That's usually durable power of attorney. If they're not incapacitated, and there is also a representative, well, that's great. But we have to give that person the same information we give to the patient. The patient can tell you orally or in writing who is their representative. It doesn't have to be in writing. They could walk in with a family member and say, this person is my representative. Great. Consider them to be one person, the representative and the patient. On the other hand, you have a patient who's incapacitated. Now, I want to say incapacitated could also be incompetent. We give that person, that representative, that individual. And especially if they come in with an advanced directive, that's great. Because then you have it in writing. This is my designated person. If they don't, then whoever says I'm their representative, that could be a spouse, a domestic partner, other family member, could be a minor's parents. That's usually who it is. In that case, what we cannot do is we can't ask for supporting documentation to prove it unless more than one person shows up saying I'm their representative. If you are going to refuse to recognize that person as the representative, document why. There may be a specific state law for doing that. That's why, again, if these issues come up, maybe your risk manager or if you're the risk manager, your council may know that. And that's why you want to have those policy and procedures so staff don't have to try and guess or figure it out when it comes time to be doing. What do we have to tell the patient? What's included in that notice? Confidentiality and privacy. Pain relief. We may not take it all the way away, but at least we're going to work on it. That they have a right to refuse treatment and also to give informed consent or informed refusal. They can have or make advanced directives to which we will honor, get a copy of their IAM notice, again, that important message notice, or a detailed notice free from unnecessary restraints and to determine who their visitors will be. Again, the visitation is the only one that translates and is included within the critical access. We have to notify patients of what those rights are and giving it to the representative. Also document why you're just giving it to the representative, and this is when the patient's incapacitated or incompetent. They're unconscious. Maybe it's a support person, DPOA, whoever that happens to be. That's why I suggest you might want to think about putting it back on your general consent form. Have that maybe on the back of your notice of privacy practices, wherever you want to put them, to get saved paper. Just remember to put it in the language the patient can understand, whether it's a different language or you make the understanding of those terms very easy to comprehend. You might want to add down there a sentence, I hereby acknowledge I received a copy of these rights and have them initial it. If they refuse to initial, yes, go through the same steps of documenting patient refuse to sign off on it. Included in there, they can contact what's called BFCC, Beneficiaries and Family. That's a QIO. It's a contracted service. Each state has one. What this is, if they contract with Medicare and insurance companies when they're taking care of Medicare patients, it's like here's how we overlook care provided to you as a Medicare or Medicaid recipient. It can be a complaint, EMTALA violation, early discharge, whatever it happens to be. They will come in and work on behalf of the patient. Just keep that in mind. That's who they're there for. I'm going to move over to very briefly Section 1557 and interpreters because this so heavily plays into complaints regarding patient rights, communication with that patient. This is part of the Affordable Care Act. There were changes back in 2020. I am anticipating there's going to be some more changes coming through in the next couple of years. Just basically, we can't segregate or deny services based upon the protected class of race, color, national origin. But on the likewise, we cannot force a provider or a hospital to do something that's against their religious beliefs, such as sex reassignment surgery. We just have to treat individuals. We cannot treat individuals inconsistent with their gender identity. This includes access to facility bathrooms. Perhaps it's rooms that they're going to be placed into. On interpreters, and this is again where we're getting some complaints on interpreters, we do have to provide timely, qualified interpreters. That's when doing the oral interpretation is a good way to help patients get this meaningful access. We provide them free of charge. That means we can't require them to have their own. Please do not rely on a minor unless it's an emergency. They come in with mom or dad, and they can at least give some information. What's their name? Do you know your telephone number? Do you know your address? Basic information. We can't use low-quality video remote interpreting. You can use it. It just has to be good quality so there's no stops and starts and fuzziness, et cetera, and especially when you're doing sign language. And of course, we don't want to delay that assistance with patients who need that limited English proficiency. It needs to be readily available. We have to make sure our interpreters are available and that they're qualified, not certified, but qualified. You can use your staff, your healthcare staff for this. I would urge not using ancillary services such as housekeeping, maintenance, those types of folks. Your nursing, your physicians, as long as they're very competent, qualified to do that, in other words, they can take the information provided in English and translate it properly and accurately to that other language, and then vice versa, that's considered qualified. And that's why it's so helpful when it can be the healthcare staff, because they understand the medical terms too. Document when you do use an interpreter. Now, I don't normally address joint commission, but this is in the patient-centered communication standards that might help. And I believe I have a reference in the appendix on what is considered qualified. These folks also have to keep confidentiality, that they have to sign that ethics or have those ethics training that we're not going to talk about this outside of our job. Signs, taglines that are required under OCR. You have to post a sign in multiple languages about interpretive services available at no charge. Fifteen, in most states, you know, five states, including District of Columbia, have 17. And what they've done is they have taken 15, 16, 17, and they put it on one line and tell you what those languages are. That's why you want to add this to your early skills lab, so staff know and understand what is your policy and procedure. Look at that, make sure it's still up-to-date and it's still current with what the regulations are. Then, again, I mentioned it's available at no charge. If you own the physician practices, make sure that interpreters are there for those appointments. Because, again, if you as a hospital own them, then they have to meet those same requirements for interpretive services available. I did mention certification was optional. I have two resources, Certified Healthcare Interpreter, and then Core Certification, that's your very entry level. And I've included the link here, you'll have to copy-paste it to your CIRF engine. They even have a website to find out where, is this person actually a certified interpreter? You can use the language line, that's totally appropriate. And sometimes that's more readily available than an actual body, again, as long as it's reasonable. So let's say you have a patient who is being admitted and absolutely, or is in the ER, they absolutely demand, no, I want that person in front of me. If it's not reasonable, meaning they're in trouble physically, they have a condition that requires, hey, we got to get you taken care of right now, using a language line or what we used to call the green monster, where you just get them on the phone and use that or they're in front of it, that's okay, because that's reasonable to give them the best care at that time. Now, that doesn't mean it won't change and perhaps, you know, things calm down and you can't get an in-person interpreter, great, that's what you can do. Again, it has to be a reasonable accommodation. All right, Graben says, now we're going to go back to the actual manual. And here's our first question, Lindsey, will you put that up? Absolutely. Okay, so you should all see this question on your screen that asks, our grievance process requires, you can check all that apply to your organization here, but only take the complaint and nothing more, name and method to reach the person in charge of the process, telephone number for the state agency and or a written policy that includes follow-up with the patient, family, representative. We'll give that up just for a couple more seconds here, see your responses coming in. And for those of you who joined us after our initial introduction this morning, if you have questions for Laura throughout the presentation, you can go ahead and be typing those into the Q&A option found there at the bottom of your Zoom window, or of course, in the chat, if you don't see that Q&A option, so we can make sure that we're addressing your questions as we go throughout the presentation today as well. And the reason I bring this up is as far as what are we doing, there has been some back and forth with Ashram, those of you who might belong have seen this on their listserv where it's like, what's a reasonable time to get these done? And what does CMS say about this? What's Joint Commission say about this? So I'm going to talk about what does CMS consider a reasonable timeframe on grievances and complaints, but it still keeps coming up, which I'm somewhat surprised that we're still having this conversation, but that's okay. Okay, we've gotten some good responses here. I'll share those results. Wonderful. All right. It looks like you guys are doing really good. You're doing a lot for responding to these grievances and complaints, and that's great. And I'm going to touch on some of the other issues in there. So overall, you just have to have a process for prompt resolution. And we have to tell each patient, where do we file this grievance? They include a definition in the actual interpretive guidelines, which you may want to just copy paste into your policy. No reason you can't. If you happen to have Joint Commission accreditation, look at combining your policy and procedure. They did that in the complaint section. It's the rights 010701. It's very similar to what CMS is saying. And again, I would suggest you use that definition from CMS right in your policy. So here's that definition, formal or written, verbal complaint. When it's verbal, it's about patient care that you couldn't take care of right there by the staff who are present. It can come up a patient, a representative, and it regards their care, and can unfortunately go to the issue of abuse or neglect. It's related to the conditions of participation and those compliance with those conditions. A Medicare beneficiary can file a billing complaint related to care under these conditions of participation. So, for example, let's say a patient filed a complaint and saying, you know, I got billed for being in restraints, and those restraints weren't necessary. I didn't have to be put in four-point restraints. That's a grievance. So you might want to look at that one, even though it's a billing complaint, because I got to pay for it. But there's an underlying issue involving those rights. You have to have a way to deal with minor requests, you know, as opposed to a written request. Here, you don't have to have a written response. So let's say Cinderella calls up and, or complains about, you know, my room was really cold, and there was a lot of things going on and I didn't like it and I didn't want the curtains closed. You could have taken care of it right then and there or give her fresh linens, whatever it is. However, if that complaint couldn't have been resolved at the time or maybe there's further action you have to do, it is a grievance and all of the requirements must be met for that grievance. Cinderella calls or writes in and says, my stepsisters were really, really mean to me when they were taking care of me and I want to complain about that. That's a grievance because you couldn't take care of it and you have to investigate it. Well, somebody else complains. If the patient, it's not the patient making that complaint. Get ahold of the patient, make sure they are the authorized representative. Get their permission. Can I respond to this because this is still HIPAA because it's talking about care. Document you got the permission. If you want to go to the extent of getting that HIPAA compliant form signed, that's your decision. You are not required under the CMS regs to do that. What is a grievance? What's not? A written complaint. If they telephone it in after discharge, anything about abuse, neglect, anything to do with harm, then it is. Now they do say in there unless it could have been routinely handled, I would not go to that extent. I wouldn't push my luck on that one. Just as a suggestion, but if there's anything to do with harm, act as though it's a grievance. And if the patient says, yeah, I want this handled as a grievance, I want to see what you're going to do about this. It's not. If the patient's cool with it and they're going, yeah, it's not a problem, but the family isn't. Billing, unless again, it's a quality of care or it's something on a satisfaction questionnaire. Unless they do put in there, I want this acted as a grievance. So here's just some examples. Again, here's a grievance. Patient goes to the nurses, I'm missing some money. And I think one of the staff or housekeeping might've taken it. That's a grievance. You get an email and it goes to you as the risk manager. Doctor didn't diagnose my condition and now I'm dying. Yeah, that's a grievance. Well, because you have to investigate it. What's going on here? Why did this occur? Now with the money, was there harm? Not personal harm, but there was financial harm. My food is cold. Something that comes in as an anonymous complaint. Well, you can't handle it if you don't know who it was because you could have taken care of at that time. That's what they're looking at. The surveyor is going to look at your policy. They wanna see and make sure that it encourages staff to respond. Be alert to these issues when the patient's complaining. Make sure that anything that involves where it puts the patient in immediate danger or harm are resolved. That goes to the top of the file. They get resolved immediately, if not timely. And do your audits. Make sure you're following your own policy and procedure because again, you will get cited if they find out staff has not done so. Surveyor's gonna talk to patients also. They wanna know, were you told how you can file a complaint or a grievance? And that includes the State Department of Health or state agency, whoever it is. And that you've included the email address for both. How do you do this? How do I handle it? Document you've given this information to the patient because they'll look in your record and then they'll go down and talk to them. How did they handle it? Will the patient remember? I can't answer that. I guess it depends on how sick they were when they came in. Who else took it? You may have to remind. Remember that we talked about that back of the paper. These are your rights as a patient here. And then, oh yeah, yeah, I just signed so many papers I forgot about it. Prompt resolution has, this is where some of the discussion has been coming up. You have to have a way to do this and tell each patient who to contact to file. That's their name and their title. Now, I reached out to CMS a while ago because a good question came up. Well, we're concerned about retaliatory action when the response comes back from that grievance manager and it wasn't what the patient or family wanted. Now, that's a very valid concern, especially nowadays. And I was a little disappointed in CMS's response. It's like, this is what the code says you have to do. You have to give them their name and include their title and how to contact them. So I'm sorry, folks. Operator, where do we route these calls? And make sure if there is a form that you have to fill out, everybody has access, whether it's a physician, a nurse, housekeeping, whoever gets it, they have to know where do I get that form. Briefly, the governing body, governing board has to make sure they have to approve and they're responsible for this process, that it works. And the reason that they put it in is because CMS wants these things elevated to that C-suite, that administrative level, so that they know what's going on in their hospital for which they are responsible. Have a way to address those complaints timely. Work with your performance improvement. Add that in there. So you may see something we can improve upon it. Is the food getting there cold because maybe dietary is short on staff? What is it? Or maybe we need to replace that piece of equipment, dietary, it could be something just like that. Most of the governing boards will delegate that to hospital staff. They still need to know what's going on, but they delegate the process for handling them to this because the board has to review and make sure these are resolved. That delegation, by the way, if it's going to a committee, that has to be in writing. The process is reviewed and analyzed through your PI program. Is it still working? Are staff doing it? A committee has to be more than one person. It cannot just be one individual. And it has to have enough qualified people to review and resolve. That could be food service. That could be your chief nursing officer, chief medical officer. Maybe it's the head of ER, whoever that happens to be. Don't forget to include those non-healthcare providers, especially when you're seeing an uptick in maybe those non-healthcare complaints that are coming in. So your process has to include a way for timely referral of these concerns, including quality of care, premature discharge, that goes to your quality improvement organization. Again, each state has one. I've got the link to find out which one is in your territory. They are CMS contractors. And again, they look at the quality of care for Medicare beneficiaries. That's their aim. That important message, detailed notice, give it to the patient within 48 hours after admission. If it's more than two days, give it before their discharge. And we talked about this previously. That's so they know what is their status because that impacts who could pay for it. They updated these forms, by the way, just recently. Give it to all Medicare patients so they know what their discharge appeal rights are. There's an updated form, notice of discharge, and the instructions on the MOON form. These are the ones who want to appeal their decision. They revised it in April. There are questions. I have it here. If you have questions specific and I have in the appendix, a copy of what that form looks like. And then just keep an eye on those changes. When they do happen to come in Georgia, you are in region four. So that's where your region would be. The BFCCs, again, they manage all beneficiary complaints and they make sure it's a consistent review process. But they also take into account your local factors. So that's why it's nice to have these folks around. They're not coming from too far outside your area as opposed to across country. All right, back to the grievance procedure. You have to have a clear procedure so that when a patient does file a grievance, it can be submitted. The surveyor wants to look at the information that you have to make sure it does clearly explain to the patients how they do submit either a verbal or written grievance. And again, they go talk to patients. They want to make sure they understand how would I do this? The policy and procedures, which you do have to have, need to include a specific timeframe for not only reviewing, but responding to a grievance. The resolution that includes that the patient has some written notice of the decision in most cases. I added those capital letters because sometimes you may not want to do that. What you did or what you found in your investigation but it must include the steps you took to investigate it, the results and the data completion. Now, this is where you might want to work with your counsel on this or legal representative. Some of the professional carriers will have those folks within their claims department or their legal department who might be able to assist you so that you're not telling them something that normally you wouldn't have to disclose like it would have come out, say in a lawsuit, you know, okay, so the patient's complaining about their medical care and that the physician went in on the wrong side and the patient ended up having scars and more complications. What you have to investigate that. Yep, we looked into this and that's what we did. What you don't want to do is turn over peer review information because that is not discoverable. And that's why when you have those kind of on the fence sort of items, please work with your counsel on that. Otherwise, this is what we did to investigate. We talked to all of the nurses, we reviewed your record. What we found was that you were at a stage of your recovery that there was no further improvement that could have been done. And so therefore you were ready for discharge. And here's where we closed out your file, the data completion. That's it, that's what you have to do. Okay, here's that timeframe, the seven day rule. CMS finds that seven days is considered appropriate to receive, review, investigate, and then come to some kind of a resolution or decision on these. If it is not resolved or you're still continuing with investigation because people are off, out of town, a vacation, whatever, you have to notify the patient and or their representative, we're still working on this. We will follow up with you when we have more information or when our investigation is complete and we have the decision. But they consider seven days, okay, that's what they say. Now, what they don't tell you is that business days or calendar days, they don't. Shorter may be better in your best interest, but again, here they don't delineate it. I believe Joint Commission, DNV, if you happen to have DNV, also that's the Del Norte Veritas, it's very similar to CMS. They did put in their seven calendar days, I believe. So investigation, usually they're not so complicated. You don't have to spend weeks looking at it. They will look at, the surveyor wants to see the timeframes that you did set up. And if it is so involved, so complicated, again, not only do you tell the patient we're working on it, but you must respond to every substance within that complaint. Whether it's because the nurses were mean, I fell on three occasions, nobody was watching me, whatever it is, you have to respond to each and every one of them. The response is meant to be an explanation to the patient in a manner they can understand. And don't forget our low health literacy. It has to include the elements that I put in this section, not statements used in a legal action. We were negligent in this respect because we did not do A, B, C, D. That again, work with your counsel on that. I can't stress that enough. I've seen just, unfortunately, too many of these grievance responses that end up in court and they go, oh, geez, those are not protected. They must be turned over. And of course, what did you do to investigate the complaint? Who did you talk to? What records did you happen to review? And the surveyor will look at those written notices to make sure you've complied with that section. If a patient emails the grievance or complaint, you have the authority, you can email back as long as your security system allows it. Because sometimes going back, it's not gonna be encrypted. Keep what you've done. Keep evidence of that investigation and your requirements. Where you keep them, that's up to you. Whether it's in a locked cabinet in your risk managers, your quality, whoever has that authority. It is also considered resolved when the patient is either good with what you did or you've taken appropriate and reasonable action. So you may not satisfy them, but as long as you've done what you can, then it's considered resolved. Include in your grievance procedure on who in your hospital is to investigate those. And especially for 1557 allegations, discrimination, denial or delaying care because of those protected classes. Again, you have to provide prompt and equitable resolution and let the patient know what you did. There were changes that was part of the 2020 changes to include when we have such a grievance under 1557. Otherwise keep copies and files of your investigation, complaint coordinator, advocate, they're the ones to investigate it. Anybody who is an interested party, that could be the staff who took care of the patient, could be the physician who took care, whoever it is. They have, they must be given the chance to submit evidence in response to that grievance because there may be something that's not in the record and that we need to include. Oh yeah, I remember talking to the patient about that, but I thought it was resolved at the time when their food was cold. I thought it was all taken care of. Something as simple as that. Just again, they have that right to respond and say, wait a minute, this is what I did. Again, the person, they always can file a complaint with OCR under 1557, those protected classes. And in fact, OCR has an entire section on how they file a rights, civil rights complaint. And they have multiple options. They can fax, email, U.S. snail mail, then go to the complaint portal. Those are for the ones in denial, discrimination based upon a protected class. How does the patient exercise those rights? That includes consent and advanced directive. Overall, they get to participate in the development of their care plan. And that includes inpatients and outpatients. It includes discharge planning and pain management. What this does, what this requirement does is it requires the hospitals to actively include the patient in their care plan and any changes that might come up. For example, we are now ready for discharge. And this is what we're going to be doing, include the patient in that. The patient representative take actions to determine who's that is, same requirements. If they're competent and have a representative, you have to include both of them in that plan of care development. Incapacitated and advanced directives, whoever's ever in that advanced directives. Incapacitated, no advanced directives, whoever shows up and claims to be it, unless it's more than one, and then you can ask for that supporting documentation. The patient representative document when you don't allow that person or you don't want to include them as the representative, there may be some issue you're concerned about with this patient and their care that maybe the representative is their caregiver and you're concerned about abuse or neglect. Policy and procedures, you need to teach your staff on that. What can they expect? Because we know these issues crop up at about one in the morning through the emergency department on a weekend or a holiday. So that's why it helps to have them trained. What am I supposed to do? And the policy really needs to promote that expeditious non-discriminatory resolution. And it doesn't matter if it's the patient or if it's the representative, whoever it happens to be. Next, the patient has a right to refuse care, document it when they do that. And that includes legal representative when it's like a minor or an incompetent person, if that representative said, no, we don't want that caregiver. The plan of care is an often cited deficiency because just because you have an interdisciplinary care plan we still have to have a nursing care plan. Patients who need post-op care, we have to make sure they're given those choices for an acute care, whether it's home health or long-term care and they have to be in writing. And pain management, other patient care issues and discharge again. This is a very frequently cited deficiency. Patients have a right to make informed decisions on their care. What is their diagnosis? And they can request or refuse treatment. Now, I want to point out thing, just because they have a right to request treatment doesn't mean it's inappropriate care or unsafe care. They cannot demand that. Then we have to just explain it. They can sign out AMA. They can, if that's the case, try and get them to sign it if possible. And again, I always put in here, don't forget MTALA. If the patient's transferred, try and have them sign that transfer agreement. Over to informed consent. There's three sections in our manual where they talk about informed consent. Patient right, that's really, patient has a right to be informed of their care and making decisions based upon that. Medical records, that's what they want to see. What's in that informed consent. And then finally, surgical services. They have a right to make these decisions and same with the patient representative. If they're competent, we make sure both the patient and the representative get this information on informed consent. You must obtain written consent of a representative even when the patient's not incapacitated. And that occurs throughout their hospital or outpatient care. Same for if they're incapacitated. If they have that DPOA, great. If not, the representative. Now this doesn't mean each and every patient is going to have a representative. Most of them don't. Sometimes you may have an older patient or someone who's just not that familiar with the US healthcare and they want that representative. Okay. If no advanced directives, again, you can't ask for supporting documentation unless two show up. Uninformed consent. Really, the patient can delegate this, those decisions to another person. They don't have to make them. Any informed consent for treatment or surgery, same thing. Patient doesn't have to make that. They do have to be informed of their status, be involved in the planning and care, but actually giving consent can be delegated. Decisions on discharge planning, same thing. They can delegate it. They can request or refuse treatment. And again, the policies, we have to make sure that they can do so. Moving over to disclosures. This is still under giving patients information. There's two disclosures we have to do in writing. If you are a physician on hospital, you have to tell them that. Secondly, you have to tell them if a doctor or ED physician is not available 24 seven to provide an assist in emergencies. That's why you may want to put that sign up in the emergency department. If you have it signed by the patient, they recognize that. And again, these are the two, if they're not available or if you're a physician owned hospital. Do it at the beginning of inpatient stay or visit. If they are a physician owned hospital, make sure it's included in there that physicians may not refer them to the hospital where they have ownership. And that you have required this as a part of their conditions of privileges. Give it to the first opportunity. Over to advanced directives. Patients have a right to decide what's gonna happen to them when they can't make these decisions. We have to provide care consistent with the directives and include that they can delegate this to their representative and they can designate a support person to make on visitation. That's a little bit different than a representative. Policy have clear statements and any limitations on conscious objections. And again, this is under 1557 where you as a hospital provider can say, yeah, no, that's against my religious beliefs. I'm not going to do that. So we have to have a statement in there that we have certain physicians where, or staff, where they may have a conscious objection to providing a certain care. In that case, it is simply the provider. It could also be the facility, but we need to give the patient the heads up on that. Give information on their rights under any state law that may be there. For example, what do you need to provide under your state law as it relates to discharge or perhaps when they're under the custody of police. That's, again, where you really need to work with your counsel on that. They say you should give notice to outpatients, emergency department, observation, same day. Should, it is not required. And then document whether or not they have an advanced directive. That's always good to know. It's great if you can get a copy. Maybe you won't get one unless they're actually admitted. Otherwise, we can't condition treatment if they do have an advanced directive. Again, it's not a way to demand inappropriate or unnecessary care. We have to make sure that we're compliant with state laws on advanced directives and provide and document that you've given education. Again, get a copy if you can. That's awesome if you can. Most of them, you probably won't get it. And train staff. By the way, you also have to do community education. I would put it on your website. This is how we see advanced directives. If you're coming to our hospital as an inpatient, please bring a copy with you so that we can make sure we're abiding by your wishes. Something as simple as, again, on your website to provide that community education. Other rights. Durable power can make decisions when the patient can't. You want to make sure you disseminate the policy so everybody knows it, including the physicians. Education, that's relatively new to the patient rights. We'll talk about that as we go along. Here's another new one that we have to do. We have to notify people when the patient's admitted and also their physician if they don't know about it. So now we have to ask every patient on admission and documented, who do you want us to notify? Do you want us to notify your primary care provider? Now, there is some requirement in the interoperability where you have to automatically do that unless the patient says, no, I don't want them to know. So there's somewhat of a conflict here, but they did rectify it by saying an interoperability, which is a medical record. If the patient says no, you don't do it. Otherwise, we have to tell them you have a right to let your family, your friends, and your physician know you're here. If they're incapacitated, try and notify that representative or family member as soon as possible. If they come in with them and say they're the representative, great. Again, no documentation required unless two people say I'm there. Okay, we're gonna move from admission over to now our privacy, safety, and our ligature risk. And this is just ligature risk, not yet restrained seclusion. We all know we have a right to personal privacy while we're in there. And care in a safe setting, free from abuse or harassment. We were gonna respect them, give them comfort and dignity. And it's not just while they're taking a bath or going to the toilet. It's when maybe there's an exam going on, that the door, the curtain is pulled to give them that privacy. Under video and electronic monitoring, we do have to have their consent. That must be a clinical need. So that's why we have to make sure patients are aware of it and they can see the camera. This could usually be like in your sleeping rooms, maybe in the ED safe room so that we keep the patient staff safe. Doesn't apply to hallways or lobbies. It does apply in stairwells so that patients and others are aware. By the way, here it is. This is the consent. We just need to let them know we do video and audio monitor in our stairwells, our lobbies and in our hallways. That's enough. Just make sure they're aware of it, including your mission consent, that they know this. And we do this, of course, for a violent, self-destructive restraint and seclusion when they're in both of them. You may want them in most of your rooms for safety purposes, like ICU. Maybe that room is a little bit farther away from the nurse's station and they can't see them. That may be a good reason to have those cameras for that security. Otherwise, people who aren't involved with care really don't need to be in there on an exam unless the patient consents. Like if you're a teaching hospital, that's when you want to make sure the patient understands. This is a teaching hospital. People need to be in here for educational purposes only. But again, can they refuse? And most likely, yes. No, I just want the doctor in there and maybe one resident. Information in the directory, you don't disclose it without telling the patient in advance. They have to ask for the patient by name. You can use information for payment, healthcare operations. We know that. That's under HIPAA. It's been around forever. And have a policy on restricting access to records to those who need to know. Speaking of which, using disclosure of PHI. Incidental uses, disclosure, they're okay. It's on the outside of the door. It's on the spine of a chart whiteboard set. List those who are present and who are packing. And you wonder, why would they allow that? Because that's a restricted area. That's folks who need to know, who do we have in here? Otherwise, take your reasonable safeguards. Speak quietly if you're in a semi-private. Sometimes that can be challenging when the patient is very hard of hearing. Always passwords on computers. That's not new. Access to when there is a whiteboard or at least limit the information you have up there. And ask patients to stand back when you are registering patients. The surveyor, they are going to walk around and listen and look. They want to determine if privacy is maintained throughout the entire visit, whether it's an examination or just personal hygiene. They'll look to see if names with PHI is in plain view. They'll ask if patient names are posted in public view. Like, okay, why do you have all these patient names up here when it's not necessary? Over to safety. See, they have the right to get care in a safe setting, whether it's environmental or infection prevention. Security, medication errors, falls. And really, this is a very broad authority for patient safety issue that we have to make sure our environment is as safe as possible. And of course, that safe for dignity and comfort. Here's examples in safe care. Washing my hands, believe it or not. Unwanted visitors. And how do we then control contraband? And then policy on background checks on all your staff to make sure, yes, indeed, these are safe folks. So again, doesn't matter where, we have to provide that safe environment. So here's question number two. Lindsay. And this one, Laura, I do not have up as a polling questions because there are no options here, but you can type into the chat your response here. So it says that Baker Hospital has a busy emergency room that frequently sees patients with behavioral health issues. So patient R presents with suicidal ideation and is placed in a room close to the nurse's station. He is not placed on suicide precautions, but the room is cleared of sharps and the wastebasket. Five hours after admission and with a plan to transfer to a behavioral health facility, patient R cannot be located. Around the same time, EMS brings a patient to the emergency room who was hit by multiple vehicles after running into traffic on a major interstate. The patient dies shortly after admission and is eventually identified as patient R. So you can type into the chat here, what citations, if any, might Hilltop be issued? And I'll give you a couple of seconds to type those comments in the chat. There are, yep, just a couple of questions that have come in. So this person asks, would you include in the follow-up letter that the review determined the care was appropriate or standard of care had been met? I would say the care was appropriate. Saying standard of care was met might open you up. Care was appropriate. Given what we did, we find that our care was appropriate and therefore we're gonna close the file. Perfect. Okay, and the last question before I move over to the chat, go over some of these comments here. It says, if we don't have a copy of the POA on file, the patient is cognitively intact and a care decision arises when the patient disagrees with the reported POA, who are we obligated to listen to? Patient. If the patient is competent, is that, I believe that was in the question, correct, Valencia? Yes. Great, yeah, patient wins. Patient wins. The patient, you do what they say. The DPOA, normally they only act when the patient cannot act. So if this patient is competent and said, this is what I want done, this is what I don't want done, we'll take into account what you're saying, durable power of attorney, but this patient's competent, we're gonna abide by what they request. Perfect. Okay, I don't see any other pending questions. I'm gonna move over to the chat. Here's some responses here to this polling question here that says, lots of failure to protect patient, not monitoring a suicidal patient appropriately, did not provide safe environment, no suicide precautions, safe environment, failure to provide suicide precautions. Yep, so lots of those same comments there. Great, yeah, absolutely. We didn't provide a safe environment. Because remember, it's not only for infant abductions, but elopement. We have to make sure that patient was safe and he just got up and walked out the door and was hit and killed. All right, ligature risk. This, and again, I'm just talking ligature, not restraint, seclusion, yeah. New guidelines came out in July of 23. They said, we want a safe environment so patients don't hang themselves or strangulate others. The intention behind this all, look at the care each patient receives. In that environment, would a reasonable person under similar situated situations as the patient consider that safe? So it's a reasonably prudent person standard. By the way, no waivers for ligature risk deficiencies. You will be cited. You must do monthly progress reports if there's a ligature risk citation. So here are the guidelines that you wanna do. First, do that patient risk assessment. How sick is this person? What is the chance they're going to harm themselves? Have they done it in the past? Put those risk assessments and your environmental risk assessment strategy into place. Are there doorknobs? Are there handrails? Something they can tie something around and choke themselves. This is an added noncompliance to include risks that don't pose an immediate jeopardy, but still look at them right away. Now, there is some timeframe that CMS or the accrediting organization will tell you this is what you need to do. On the definition, they do give us a definition in the interest of time. I'm not gonna go too far into this because I really wanna get into restraint seclusions. We know it's anything you can tie something around and for the hang themselves, whether it's a shower rail, it can also be your belts on your patient. But don't forget the housekeeping carts, your utility carts, because that could also be a cleaning agent or disinfectant, something they can harm themselves with. You want a ligature free in your behavioral health units, ligature free. Anything that can be used to harm themselves needs to be taken out of there, like plastic bags in the trash can. What you're looking at is the insulation from a window that the patient pulled out and used to hang themselves. Psych patients in non-psych settings must also be protected, whether that's ICU, if they're on a step-down med surge, ED. Again, we wanna identify those who are at risk for self-harm that may be one-to-one monitoring. So somebody sitting in there with them or outside their door to keep an eye on them, taking things out of the room so they can't harm themselves or use as a weapon. Any deficiencies have to be corrected within two months, 60 days from once you get the report. And then they're gonna come back and visit and do another follow-up. So you need to provide education and training to all staff, volunteers, even if in hospital as a contractor, agency staff. They need to know what poses a risk for that particular patient. Now they do say, do this training and update every two years that's a pretty good refresher, especially when you have behavioral health patients or you're seeing an uptick in these patients. Look at those environmental factors. This applies to all sections of the hospital. That's your psych units and psych hospitals or ligature resistant, one of those two. There is a behavioral health design guide. It's from 2022. There was supposed to be an updated version out last year. It hasn't come through. It has not been released. Once it is, I will put it up here. But again, I don't, that's not been out yet. Hopefully it will be out pretty soon. So that's ligature-free. Now we're gonna go over what happens elsewhere with this patient. Free from abuse, all forms, harassment, neglect. That's why we have to have a way to prevent it. Criminal background checks, they may be required by your state. Do ongoing training. What is abuse? What is harassment? What is neglect? Proactive approach to identify those issues and those events. Policy and procedures are required to do this. And they even talk about inadequate staffing that that's included. They included definitions. Again, you may wanna include these in your policy. Abuse, that willful infliction of injury, but it could be intimidation that could result in mental anguish. Staff neglect or indifference to, oh, that hurt you? Oh, that's too bad. I mean, yes, certain things we do do. It's like, I am so sorry. It's going to be uncomfortable when we do this. That's not abuse. It's when you say, too bad, so sad. That's abuse. Make sure they're in there on what you have to have. Neglect, that's what we don't provide, but we have to, we're supposed to do that to prevent harm. Could also be mental anguish. You wanna investigate any of these allegations and do it thoroughly. Of course, we don't hire those with a record of abuse or neglect. And then don't forget you have reporting requirements, whether it's to the Board of Nursing, Board of Medicine, whoever it happens to be. We're going to talk certain reporting for death when they're in restraint and seclusion later on, but you might wanna also consider, do you need to notify law enforcement when there's abuse and the patient or others have suffered injury? That's where again, and I hate to be redundant in this, check with your in-house counsel. Who do we need to notify in this respect? There have been cases where abuse to psychiatric patients hadn't been reported and it was pretty significant abuse and law enforcement was not notified. The issue, the facility had to close because it was so, that was a bad thing when it wasn't reported and they knew it was going on. Other consideration, abuse freedom means from other patients and visitors. Effective program includes prevention. So yeah, having enough staff who've been screened is crucial. What events could lead to it or contribute to abuse? Remember, neglect can also be burnout where staff isn't responding to those call lights. Protect during the investigation, meaning you may have to put the alleged perpetrator on leave or moving the patient to another unit when that's not possible. And then investigate, report and respond. Have a policy for investigating, make sure you have enough staff across all shifts. Make sure it's true, that even if it's not true, that you've taken actions, especially when it is substantiated. Make sure staff know what it is to do, what they're to do if they witnessed it and policy and training on any state or accrediting requirements. So with this abuse and neglect, they're taking it very, very seriously. Confidentiality, well, we know they have a right to confidentiality in their person, but also their medical records. That's why HIPAA was created, that we need safeguards to ensure that it's protected. But we also have to make sure under here that we have access for the patient. HIPAA compliant authorization when you release it and minimum necessary standard. We keep records secure, only reviewed by those who need to know they're involved. And of course, we no longer post information where it can be reviewed by visitors. Now here's access. This is when I wanna look at my record. I have a right to access my information. I can inspect my records. I can also get a copy of it. I can tell you, or I can be nice and send you a written authorization. And it has to be, we give it back to them in the form they want it, electronic or hard copy. And of course we know we can't put up barriers to have patients get their medical records. Access is their current medical records. And that's within a reasonable time. So you may need to look at your policy. What is a reasonable time given your size, et cetera. Tell everybody, nurses, doctors, other staff and a way for patients who may be they're inpatient and they wanna look at, okay, what's been going on today or yesterday. If that's in a room with a laptop and it's only their record, that's it. That's all they can access. That's a reasonable accommodation. Otherwise we know they get their records within 30 days unless offsite. Now CMS says timely, but check your state law may be shorter, more stringent. Entire record or a specific portion. And they don't forget, they have to include that discharge planning documents. Under OCR, Office of Civil Rights, for those of you, and I apologize if I didn't explain that. OCR is the one who investigates these rights or complaints when a patient feels they've been discriminated against. And now CMS is saying, in addition to what OCR is saying, you know, with what we have now, really we need to get them these records within less than 30 days. This overlaps with what OCR also says. OCR is a very long memo that talks about access to records. So if you need something to do, there is a memo out there on access for records. But essentially I have the right to know what's going on in my record today. And we have to give them access to doing so. It's access to all information. They can inspect them. You can email it or fax it. Just of course, verify their identity. We can't require them to request records in person and we can't require them to mail in. They just, if you're going to release the records to the patient, you may wanna get that authorization. So we know where it goes and what they want it. Just simple, they can request copy electronic X-rays. They get a copy of those and send within 30 days. You can charge for records, no retrieval fee. Include in there when you can deny the request, say it's psychiatric treatment records. And we can't refuse, of course, if they haven't paid their bill. Timely access. OCR is getting many, many more complaints on that. Now, fortunately, there was a slight dip in 2023 because OCR will fine you if don't get them in in time. One in every 10, as a matter of fact, because patients didn't get their records timely. Here's one from 2020. This was right of access. Again, I wanna see my records. Didn't happen, $100,000. Here is 160,000 because they didn't get access. And by the way, it applies to not just hospitals, but providers. A dentist office can also be fined if that's the case. If the patient's incompetent, their personal representative, I would have them sign a form, something, say you assign their personal representative. You can do a reasonable cost for copying or postage, but no retrieval fee. Open records. With limited access, again, they have a right to get access to whatever's in there. Notes, HMP, progress notes. And this is also in the medical records, conditions of participation. And then just to wrap up some medical records, here's some proposed new regs. And I haven't seen them come out yet even though they've been proposed for some time. I've got the link there. Patients can inspect and take notes or photos. You decrease the time from 30 to 15 days when you give it without charge, electronic records. And they changed the wording. And really this was nice because they expanded your ability to disclose protected health information, to ward off a threat to health and safety when the harm is seriously and reasonably foreseeable. It's a lower standard than where you are now. Now it is serious and imminent. So they've dropped that level of the bar and now it's reasonably foreseeable. You get a patient in who's really under a crisis or maybe you've been treating them for some time. They're inpatient. And they say, you know, once I'm out of here, I'm gonna go and shoot so-and-so in the head. That's reasonably foreseeable. Yeah, they're going to do that. They may have been in there for some time and still have these things. Then you have a right to disclose that information, perhaps to the person they've identified. If it is something where you can't identify the person, again, to law enforcement. They are looking to decrease that level. Restraint and seclusion. This takes up a large part of the actual patient rights section, 42 pages to be exact. Lots and lots of pages here only on restraint and seclusion. This is a highly cited deficiency. They have gone up and they continue to go up. Use of restraint and staff training are the top two deficiencies. Criticals. Again, you don't have that section. You're not required to follow it unless you have a distinct psychiatric unit. There they are surveyed under Appendix A. You do have to have a policy and procedures. How are you going to handle these restraints, these seclusion, because you will get them in. Overall, patients have a right to be free from physical or mental abuse and corporal punishment, and that includes your restraint and seclusion. We only use it when necessary. We don't use it as convenience. We don't use it as discipline. Only use when patient safety is at risk, and we take them off as soon as possible. The guidelines apply to all hospital patients, doesn't matter if it's behavioral health or they're on med search. This is regardless of where they are located. Add that to your patient rights statement if it's not there. So we have to give them a copy. Again, unreasonable restraint and seclusion. Don't consider this as part of a routine fall prevention. That's specifically spelled out by CMS. The tag number is 154, by the way. Leadership, they have to create that culture that supports those rights to be free from such, and they must make sure systems and processes are in place to eliminate inappropriate restraint and seclusion. It's only used for safety of the patient or staff, and you comply, make sure the hospital's complying with those restraint and seclusion requirements. Again, that's leadership, your board, your C-suite. Normally, and before, CMS didn't say no protocols for restraint and seclusions. Well, now that it's no longer banned by the new regulation, but you still have to have a separate order for restraint and seclusion, and it must include enough information for staff to know how do we monitor and when can they be used, like intubation, document, individual assessment, symptoms, diagnosis, why did I have to trigger this protocol for the use of restraints? Medical staff has to be involved in developing this, and they have to monitor that protocol. Is it still appropriate? And just as a suggestion, if you have the luxury of psychiatric care in your hospital or the psychiatrists, include them in the development of those along with ICU and med-surg providers. If a patient becomes violent or self-destructive behavior, they're in the units, ICU or ED. There's one set of standards that apply, believe it or not. The decision to use restraint and seclusion isn't from the diagnosis. What's the assessment of that patient? Joint commission, by the way, because of behavioral health, non-behavioral health. CMS, violent or self-destructive or non. CMS, it's the department. It's not where the patient's located, what is the patient exhibiting? So here's the definition. Again, put it in your policy. Any manual method, physical, mechanical, equipment, something that immobilizes their ability to freely move their extremities, head or body freely. Mechanical restraints, that can be anything from a jacket to belts. Manual method to hold them down. Therapeutic holds to help with the violent and self-destructive patient. There are time limits on length of the order, and I'll get that into a minute, here in a minute, as far as how long it runs. Medications can also be used as a restraint, where if it's used to manage their behavior, that is not considered a restraint, because we have to have that. We have to do that to make them able to function. But if it restricts their freedom of movement and not the normal standard or dosage, then it's a restraint. PRN drugs, it's only prohibited if it meets the definition of a drug for restraint, like Phenergan to control their activity, that's a restraint. But Ativan, when they're going through withdrawal, that's okay, that's help treating the symptoms. It's an accepted standard of practice. When it's not a restraint, if it's in their pharmacy parameters by the FDA, follow what the standards say. If it's used to treat that condition, and it's a standard treatment, that again, helps them function better, decreases that psychosis in them, improves their depression. Again, it's not a restraint. Other restraints are also included where it's not a restraint, handcuffs or shackles, where law enforcement or police have applied them. Here, your only responsibility is monitor. Watch for safety, like skin issues, tears, maybe they're really hurting themselves, just monitor them for that. Orthopedic devices, like protective helmets also, that's not a restraint. Methods that involve holding the patient to do an exam or a test, not a restraint. Helping the patient, protecting them from falling out of bed. Now, this is when it's preventing the patient from falling out of bed, like they're on that special mattress or the bed is turning. That's okay, because you can keep those rails up, so the bed doesn't slide off, or the mattress doesn't slide off, the patient doesn't slide off. But if it prevents the patient from getting out of the bed, and they can't lower the rail, then it's a restraint. Those narrow carts, the rails, it's not a restraint, same thing. IV board, unless it's tied down. Postural support, you got them positioned on their side to help with the cubitus training. And something that positions a patient during surgery or taking an X-ray, that is not considered a restraint. Recovery from anesthesia, and maybe you've got a belt on them so they don't roll over. Mitts, unless they are tied or pinned down, or they look like a boxing glove. I've got a picture of him. That is considered a restraint, especially if it's tied down. Padded rails, you can use that because that's a seizure precaution, helping hold the child to give them a shot so they don't hurt themselves more. But these are restraints, physically holding for forced medication, tucking the sheet so they can't move, a net bed, with the exception that the patient can unzip it from the inside and get out, it's not. Freedom splint, that immobilizes the limb. It's not the thing, what are you using it for? And if you have to restrain, let's say they've had shoulder surgery or arm surgery and you got to keep it in that place. It is a restraint, but it's to keep it safe from post-surgical injury. That is not a restraint. Is this a restraint? Patient's in a wheelchair and they have that Velcro band around them. If you have multiple purposes like side rails, jerry chairs, it restricts their movement, yep, it's a restraint. Seatbelt in a wheelchair, like I said, what you just saw, that is okay because it will help and they can take it off. Patient can lower the rails, it's not a restraint, just document it. Again, if they can remove it, it's not a restraint. Stroller is something that's age and developmentally appropriate. It might be, but again, if it's developmentally appropriate, no, it's not. Just make sure your interventions are addressed in your policy and even holding an infant or a toddler, that's not a restraint. Oh, here's something interesting, weapons. CMS doesn't consider the use of weapons in trying to put on restraints or put a person in seclusion. That's really a good idea. That's not safe and appropriate care. Security can carry it according to your policy and what your state law might allow because use of a weapon is law enforcement. It's not healthcare intervention. If the patient is arrested and law enforcement use it, well, that's up to them. Of course, you wanna make sure it's safe for the environment that includes pepper spray, tasers or other types of stun guns, nightsticks. All of those are included in their definition of a weapon, but use by you, your staff in the hospital, not okay. Security is what your state law says they can and can't do. Do that assessment, make sure it's comprehensive for if you're using your restraints, why are we using it? Reduce that risk for falling. Other medical problems, maybe that's what's causing their issues. Could be hypoxia, could be a drug reaction. And again, it's not considered an appropriate part of a fall prevention program. Look for other means in other words. And question number three, I think we're okay here. If we get further in these questions, Lindsay, I may just go past it in the interest of time, but here's number three. Okay, no worries. Let's get this one up here on your screen. Oh, I think I may have, yep, there we go. Our restraint and seclusion policy requires, you can check all that apply here. Patient assessment, patient re-evaluation for every shift applies throughout our facility. Review and approval by our board, medical staff and nurse leadership and or nothing specific can be applied when needed. Okay, we do have a couple of questions. Okay, Laura, while we wait for these responses and this first one asks, we could clarify if unsecured mitts where the patient can easily move their fingers but cannot easily grasp an ET tube is considered a restraint. That's a good question because when it's used in that situation, like soft wrist restraints, we did them all the time ICU because the patient by reflex would reach up and grab the tube. Those, it's considered a restraint and you wanna include that in your policy, what you have to do because that will come under separate on how often you monitor the patient, taking them off, et cetera. Is it a restraint? Yes, but there's a reason behind it. It's just how often do you monitor it and why are you using it? So yeah, you can use them. They're not forbidden, I don't wanna stress that. It's just how are you monitoring the patient and why are you using it? That is a clinical need so they don't extubate themselves and I'll get into that here as we get into monitoring a patient. Perfect, and then this last question I see asks if sheets, bedsheets are a ligature risk? Oh, yes. And I only know that a colleague of mine was investigating the hanging of a patient in her hospital and the patient tore the sheet apart so it was small enough that she could wrap it around her neck and then hang herself with it. So yes, a sheet might be considered a ligature risk. That's why you monitor the patient. How much do they need to stay warm and yet protect themselves? That's why we have to monitor. Okay, we have one more question. Yeah, perfect. One more question that just came in that asks can a hospital take the approach that the medical record is unavailable until complete and if a patient requests the records while in the hospital can we decline until they are complete? I would be careful on that one. That's an access issue. Again, if I wanna see my record, I have a right to access that record. You can explain them. Doctor hasn't entered his notes as of this day. I would be very cautious in doing that. I wouldn't encourage it to be honest. I would just let them know it's not done yet but hey, here you go. Then they can come back and ask for it later. Yeah, I think that might issue, you might be facing a citation on that one. Okay, and we'll go ahead and end this poll and share those results. All right, oh good. Okay, seclusion. I'm just gonna start with seclusion because it's really short tag numbers. This is where we put the patient against their will, alone in a room or somewhere where they are physically prevented from leaving. We only use this for violent or self-destructive behavior where it's an immediate threat of physical safety to not only the patient but others. Being on a locked unit with others or in timeout where the patient can leave, nope, not seclusion. Now, usually on a locked unit, no, they can't leave but because they're not relegated or set in their own room where they can't leave, that's not seclusion. Why? Here what we have to do is why are we restraining and secluding? That's what the surveyor is going to look for and that's where they look at the documentation and it must be specific. You may want a sheet, something, an order sheet so we can fill that out or some kind of documentation form. This is the reason we're putting them in restraint and seclusion. We want to prevent danger to not only the patient but others. Here's other reasons we want to restrain them. They're a danger to themselves, want to keep that therapeutic environment. We don't want them to take good equipment, harm others or property like throwing a chair through a window and they simply can't comply with the safety directions. They can't or they won't comply with those safety restrictions. We always want to start with the least restrictive measures and we only use restraints when we know those least restrictive measures don't work. They're ineffective. The type technique must be the least restrictive. What is the patient doing that's so much of a hazard? You may want sundowners to wander at night as long as they can safely get up and walk around the hallways or in their room, that's fine. If again, it's safe to do so. Having a patient or family put a person in restraint, that's not enough, especially if the condition doesn't warrant it. When my mom was alive, she had had a very bad outcome from a surgery and she was out of it, let's face it. And she would try to get up out of bed and move around and pull out her IVs and do stuff like that. And so in the interest of safety, even though we had had a time since, look, if you need to put her in a belt restraint or if you need to kind of restrain one of her hands, we're good with that, that's not enough. The staff had to document what she was doing and the danger it posed to her to get that order from the physician and then they just monitored her throughout the night. It eventually cleared up, but again, that's just because the family said, yeah, put her in restraints and we do it all time at home. That's not enough. We need to have a reason for it. We have to assess our patient and document what we find. And that restraint may be the least restrictive to protect them based on our assessment. Train staff on what is least restrictive interventions, whether it's side rails, all the way down to a three or four point restraint, whatever it happens to be. This goes from least restrictive to more restrictive, like left to right. Look at your alternatives. What could you do that might prevent restraint and seclusion? A sitter, having a family member stay with the patient to reorient them. That may work sometimes because they recognize the voice as opposed to a stranger. Maybe distractions so they don't harm themselves. Look at those non-physical interventions and maybe a list of possible alternatives and maybe a toolkit. Whether it's a bed sensor, a lot of hospitals do use that. As long as you're turning it on, maybe a low bed mattress on the floor, that's perfectly acceptable. Make sure there's a toileting routine. For those older patients, getting up in the middle of the night two and three times is not unusual for them. So maybe we wanna have that toileting routine. Every two hours, go in and see, you need to go to the bathroom. So it's safe and you can be with them. Licensed practitioners, your PAs, nurse practitioners, CNS, they can now write orders for restraint as long as the state law permits it. But your hospital policy also has to allow that. And that can be restraints or seclusion. So again, within their scope of licensure, consistent with their privileges that they've been granted. So that's what you need to consider. By the way, a medical student is not included. A licensed resident is, but not a medical student. Specify in your policy and procedure who can order those. If you do have to do this, notify the physician as soon as possible. Have an established timeframe. One to three hours, not exactly ASAP. Your policy has to determine who is the attending and address the definition of as soon as possible. RN, PA, those who do the one-to-one phase have to notify that attending and discuss what they found and make sure to document if a licensed practitioner or a nurse notifies the physician. We had to put the restraints on, and this is why. You do have to have an order for the restraint. Someone who's responsible for the care of the patient and has privileges to do so. Including there, what if you have to put them on an emergency and who can order? PRN is prohibited and including a medication. No PRN orders for restraints, no PRN orders for medication if they're used as a restraint. With, of course, three exceptions. It's a self-mutilating behavior. I don't know if any of you have ever seen it, but it's where the patient simply cannot control what they're doing. Whether it's chewing on their lip or their gums, they've worn down their teeth so bad, or they're chewing on their fingers, such as Leish-Niam syndrome. A jerry chair. This is when you have to have the patient and the tray needs to be there when they're out of bed so they can sit up and eat. Or they can at least be up and out of bed and don't slide out the bottom. Raise side rails for all four. When the patient's in bed, so again, they don't tip out when the bed's moving. And you don't need a new order, but just keep in mind, in these circumstances, these three exceptions, it is still considered a restraint. As with anything, restraints have to be part of the written care plan. Why do we have them in restraints? What's the goal behind that? And they should be modified in that plan of care when they can come off. What are the symptoms or the behavior of the patient? Say, hey, they're cool, we can take them out. Look at that, update it in writing. And really, it needs to have that loop. Assessment, intervention, evaluation, re-evaluation. That loop of care in the plan. So here's just some key steps and the elements that would go along with physical restraints when you are developing that plan of care. Orders are time-limited. That has to be in the plan of care. Those who are violent and self-destructive, you might want a part of a debrief in your plan of care. It's not required by CMS. You don't have to do that debrief, but it does help. Because then you talk about what did you see, what did you observe? And add that information to the toolkit, how you're going to do it. Restraints need to be discontinued at the earliest possible time. Doesn't matter how much more time's left on the order. If you are discontinuing them and you still have 45 minutes, but the behavior comes back, you got to get a new order. Temporary release to go to the bathroom, eat, that's okay. A trial release though. How are they going to do outside of here? That's a PRN and you can't do it. You take them out. If they redo, you have to get a new order. The policy has to include, you want to end these restraints as soon as possible. It's only used when that unsafe condition exists. So that's what you need to include. First off, who can discontinue them? When you can, under what circumstances? Who can take them off? And we know that's based on the patient's behavior. They're no longer going to hurt themselves. And when you need to apply in an emergency situation, the surveyor wants to see that policy. They will take some time, especially if it's a complaint survey. We have to assess and monitor our patient's condition on an ongoing basis. The provider, they have to also provide ongoing monitoring. They need to decide, can these restraints and seclusion be discontinued or removed? And removed, they took out continually monitored for a patient assessment, unless violent and self-destructive. And as far as monitoring the patient, that's up to your policy. How often are you going to monitor? Is it every 15 for the first hour, every 30, et cetera? That's up to your policy. At that interval, it's going to be based upon what is the need of that patient. They don't specify the timeframe for that assessment. CMS won't joint commission. Every two hours for medical, maybe it's every 15 for your behavioral health. Then CMS is good with that. They said that's fine. However, waking up a patient every two hours might be a little bit over the edge and actually might impede their recovery because they're sleep-deprived. Frequency of evaluation and assessment must be in your policy document to show you're doing what you're supposed to do, which brings me to documentation. Maybe you want a special sheet for that documentation, the parameters, frequency, what you're going to look at, and the hospital policy needs to address those. If the physician writes a new order or renews it, the documentation must include what is the clinical needs of that patient and why do we need to continue it? But also that we're taking care of the patient. We're giving them fluids. We're getting them up and offering the toilet. How is their circulation? If they're in a risk restraint, they can't move, what's their circulation? Removal for range of motion and repositioning, again, that's for care, that is not a trial release. What did you do to reduce the restraints? How is their skin held up? Are they still very agitated? What interventions have you used to try and get them off? How have they responded to that intervention? Did they completely shut down once that restraint went off, or are they starting to communicate better with you? And why, what were the symptoms that warranted that restraint? Document the behavior in descriptive terms. That way we can really evaluate the appropriateness of that restraint. Maybe they're trying to bite the nurses, slap them, throw things. Maybe it's a comment, like aliens are in my room and trying to take me away. Okay, we need to keep an eye on this individual. There are toolkits if you want to use that. Documentation helps, that helps with all of the requirements. It lists out what's included, what you want to consider in that documentation. Some facilities do have a separate order for behavioral and non-behavioral patients. Always follow those manufacturer recommendations on the use of restraints. Maybe there's a professional article you want to include. So this is just an example of what one of those would look like. And of course, we know we act through our QAPI. Leadership has to assess and monitor it to make sure what we are doing with restraint and or seclusion is medically necessary. And that's why a log may help. That's where you record the use of the restraints, the shift, the date, the time, who was involved, who initiated it. When did each episode happen to occur? Were there injuries to the patient or staff? What's the age, the gender, just some considerations so you can start to track this by QAPI. And of course, we use our restraints and seclusion as directed, safe and appropriate. We use according to manufacturer's recommendations. Keep a copy of those recommendations. And of course, any state law provision standards of care and practice on the use of restraints. If there's any injury to the patient in the application or use, we have to fill out that incident report, complete that, because that will go through your QAPI. Why did that happen? Was it an over-aggressive individual applying it? Or were these unavoidable injuries that in trying to get the restraint on a patient moved in such a way that they hit their head, say, on a cabinet or something? That's what you want to track. So we can use this directed. Is it a soft restraint? Is it a MIT? Or is it a belt restraint? Whichever one it is. So here's where some of that question on who's going to be doing this. The one-hour rule. The one-hour rule used to state that with one hour of application, the person who ordered that restraint has to go in and see and evaluate the patient. AMA didn't care for that, nor did the American Hospital Association. In fact, American Hospital Association sued CMS, because that's just overly burdensome and sometimes not necessary. Now, these are standards for behavioral health patients or those who are violent or self-destructive. And really, it's a time limit for use of those, whether it's a physical restraint or a medication. What it's saying is somewhere along the line, someone has to see this patient face-to-face, evaluate the need for the restraint and seclusion, and that's within one hour of intervention. So now it can be done by someone else than the physician who ordered it. Can be done by a licensed practitioner or someone, an RN who is trained. And we go through the training here. The physician doesn't have to get up and come out of bed to come in and see the patient. They can telephone in and do it. That's fine. I'll talk about the training requirements here a little bit later. We're doing this, the evaluation is done to rule out anything else underlying to contribute to that behavior. Are they hypoxic? Are they going septic? Are they septic? Is it a medication interaction? Have they slipped themselves something prior to admission that is causing this behavior? So we have to see this patient within one hour after the initiation, unless, of course, your state law is shorter. We're evaluating their immediate situation. How are they responding to this interaction, intervention? What is their medical and behavioral condition? And we do this, can we stop it or do we continue it? We have to document it and change it to capture. Change your form if you're using one to capture that information because we're looking at physical and behavioral symptoms. What is their age, their history, their drugs, their medication, anything that could agree or potentiate this situation? Document that change in the care plan. So yes, they came in, they were fine. Now something's happened. They reacted to a med. We had to put them in restraint and seclusion. We must change the plan of care. And that's why staff have to be trained in all of that. There are time limits that apply to the written order. Four hours for your adults, two for nine to 17 ages, one hour under nine. By the way, joint commission has the same parameters. And this is for restraint and seclusion, for violent or self-destructive behavior, for the safety of everyone, the staff and the patient. Not just behavioral health, it's for violent self-destructive. The original order can be renewed for up to 24 hours, but then a physician again has to reevaluate the patient. Of course, the nurses are going to be evaluating this patient. They're going to share what they know with them to get that order renewed. Again, if your state law is more restrictive, you follow that. After the original order expires, someone must go in, the provider, a physician or licensed practitioner has to see that patient and assess them before a new order is written. So again, violent and self-destructive. What if you have those non-violent, non-self-destructive? Well, here you have a little bit more leeway. Like your patient in ICU, they're intubated and you don't want them to extubate themselves. Each order can be renewed as authorized by your policy. So this can be a continual renewal of that order. But again, you have to have the policy on restraint and seclusion. I have some examples in the appendix for you on that. The surveyor is going to talk to staff. How do you know about this policy? That's why you want training on it. Orientation and annual in-service skills lab. The surveyor will look to see the use, the actual use of your restraint and seclusion to make sure it's consistent with your policy. It is a major area in their survey process, by the way. So here's the one thing, the one area in the entire acute manual where you must have training of staff for direct patient care before they touch a patient. And that's on restraint and seclusion. This is the only area where CMS, you can't touch them unless you've had this training. All staff having direct contact. It must be initial and ongoing for proper safe use. And they must be able to demonstrate competency. Yearly education, same thing. You want to document their competency and policies identify who can do this assessment and monitoring, whether it's an RN or a nurse's aide, who's going to assess that patient. Patients have a right for safe implementation of restraint and seclusion. That's why training is so important. And that includes your agency nurses. They have to be trained and show competency, not just application, but how do they take them off? How do they monitor them? How do you give care for a patient in restraint? It must be done before doing any of those functions and orientation. It must be periodic. And that's why a form helps because then you're going to cover all your bases. Again, yearly skills lab, but those who really apply them. You must require appropriate staff to have knowledge on doing those. And especially when you've got maybe a patient population. What if you have those teenagers? Teenagers are very strong. And the same with the kiddos, the younger ones. How do they identify behaviors and what events, what circumstances may trigger it? Which brings me to question four. I am going to pass on this question in the interest of time, Lindsey. So I'm just going to keep going. All right. The next thing is de-escalation. Teach staff what is de-escalation. It's not just those on behavioral health because we really want to get this patient back to where we can work with them. You know, patients come in, they're terrified. They may be injured. They may be scared. They may have hypoxia and not know what's going on. So that's why it helps when staff can identify this and start to bring them down. When a whole bunch of people start surrounding patients that are just in there and trying to figure out what's going on, what's going on. Sometimes it helps to just simply step back and say, okay, we're here to help you. What's going on? You may have a de-escalation plan that has those triggers that will set a patient off. Whether it's being stared at, a fight, people yelling around them can just do that. And so that's where here's some of the plan that you may want to consider. Choose the least restrictive intervention when you have to do restraint and seclusion. Of course, that's based on the assessment. Safe application and all uses throughout the hospital. And don't forget, how do they identify physical and psychological distress? How are you going to respond like positional asphyxiation? Clinical identification of those behaviors, maybe you don't need them. But again, those who are restrained or secluded, watch their respirations, watch their skin condition, watch their vitals. And this is a special requirement, those by hospital policy in the one hour face-to-face evaluation. Of course, we have to have first aid available, CPR, including certification. And anyone who applies, monitors, accesses, provides care, they have to have that training and first aid and be certified in CPR. These are the ones who are going to show up and provide care when needed. You may want to do scenarios. Training, you must document in their personal records, they've been trained and have the competency to do this. Don't forget your security guards, how are they going to respond? They do talk about an eight hour course and the cost that goes along with it. Those who are doing the training have to be qualified because they have to have a high level of knowledge on what is included to train the trainers, they may be doing this. And then finally, don't forget your physicians. They also have to be trained, your providers, those who are authorized to order restraint and seclusion specifically. They have to have a working knowledge of what your policy is and you determine what other training they may need. State laws, please keep an eye on them. They can be stricter, but they can't be weaker. If they're weaker than what CMS says, they're preempted. And again, they can choose to be so. One-to-one monitoring behavioral health patients that are violent and self-destructive, a danger to others. We have to visually monitor them in person. You can use audio, but you also have to use video equipment in doing so. And these again, when it's not safe to be in the room. The person who is monitoring one-to-one, they have to be trained and that's all they do. One-to-one means one-to-one. Document the record and be in close proximity, maybe at the door. Documentation includes, you've tried least restrictive interventions. It didn't work and this is what the symptoms that warranted it, how they responded to it and why we need to continue it. That has to be spelled out in your policy. Modify the assessment sheets to do so. And again, you may want to consider policy so they're not left unsupervised. Desks, this is still part of that patient rights section. Any death associated with the use of restraints or seclusion have to be documented and reported using the electronic reporting system. Safe Medical Device Act, still have to report when it's a restraint. There is the hospital reporting of deaths, the OIG report, Office of Inspector General. They put that out in 06. I have the website if you're interested. But you must report to CMS, any death that occurred while the patient was out of restraint or seclusion at your facility. Even if death occurred 24 hours after they're out of restraint or seclusion, unless the patient dies with two soft wrist restraints and then you do your internal log. That's like your ICU patient, document the record that you did also the reporting. But there's an additional death reporting requirement. If it occurs within one week after the use of restraint and seclusion, where it is reasonable to assume the use of such contributed to that death, either directly or indirectly. Now, I think this is a very broad standard. That's my belief here, because they want us to keep an eye on these. Of course, you have to know about it. But did that death occur within that seven days? Reasonable to assume because of the restrictions of movement, chest compressions, restriction of breathing, asphyxiation when we held them down or they were pinned down. Again, we report to the regional office by phone no later than the close of business than the next business day when you learned of it. You must use the electronic form. They won't accept the paper forms anymore. Add as form 10455, much more information like primary diagnosis, cause of death, why were they in the restraint and seclusion, et cetera. They're using that information to determine do we need to come do a visit? Other responsibilities, staff document in the record when you did report it to CMS. And that includes even if they were just in soft restraints, but you still had to have them. Hospitals, revise your post-mortem records and rewrite your policies to include it. Internal log, you have to have enough information and do it no later within seven days. Do it as soon as possible. And here I have on slide 187, what you include, name, date of birth, date of death, et cetera. And who is responsible for their care. They may wanna see that log during a survey. So don't be surprised if they ask for that internal death log. You're still required to report death within seven days and rewrite that policy and procedure and train your staff. So finally, visitation. Have to have a policy on visitation when you can restrict it, clinically necessary. They don't recommend restricting visitation in ICU unless of course it is clinically necessary for prevention and control. Same day surgery, they may want people there pre and post-op. Outpatient support person that helps, especially during an examination, having that second ears. Like for example, you have an outpatient endoscopy unit. For those of you who have had the pleasure of having in colonoscopy and you've gotten never said, when the physician comes around, talks to you afterwards, you probably won't remember it, them being there or what they said. That's why that support person is so crucial because they can hear it too. Policy and procedures have to address the right to have visitors and address any restrictions. Those restrictions must be clinically necessary or reasonable. Like child visitors, maybe you don't want the kiddos up there. Here's some restrictions. Number one, infection prevention and control. A court order, maybe mom or dad don't have the right to go in and see that kid or an adult when there's an elder abuse. A disruptive visitor. They're yelling, they're screaming, they're just, yeah, they're not playing nice in the sandbox, so to speak. The patient or the roommate just simply needs to have rest. Substance use program. Maybe they're having a procedure, not a good idea to have them walking in when you're putting in a central line. The support person may be the same. Again, any refusal to honor that support person to make those decisions have to be in the record and look at your culturally competent training. It may only be under their culture, a certain gender can come in and make these visits or whatever it is. Brings us to the last one. We have about 10 minutes. I'll read it. So we have a healthy, active 85-year-old, active in the community, manages their own affairs. They're admitted for a left total knee and the plan is swing bed, PT, and then home. Surgery goes along, no complications, transferred to swing bed, and the daughter is nearby and will assume care and discharge. Due to the daughter's work schedule, she's only been able to see mom for seven days. Well, when she shows up, found mom hadn't been bathed, no change in her limbs for days. In fact, she looked at the record and showed she had been given sedatives with no reason or mom had never taken sedatives and now they're giving them. In fact, there was no request for her to have them. Daughter arranged for immediate release for the mom to her care. Once home, patient wakes up and state she has absolutely no recollection of the events since the day of surgery. Any citations you think this hospital might face? So Lindsay, I'll let you decide how you want them to answer that and then we've got time for questions. Perfect. I'm gonna actually post these options up here on the screen for you all. So you can just select those here for either failure to provide safe environment, violation of patient rights, unnecessary chemical restraint, failure to provide sanitary environment, or possibly others. You can, of course, type in those other comments there into the chat. I don't think that we are missing any questions at this time, Laura. Great, great. Okay, cool. So I'll give everybody a couple of seconds to do that as you're also putting in your responses here. I see somebody posting in the chat all of them. Those are your responses. And that's a good response too. Yeah, they may actually get cited on each and every one of these. I only included that second one, patient rights. That's a pretty broad one. I understand that. But yeah, you're right. It could be all of the above. Yeah, I see lots of other comments here in the chat saying all of them. And they were. They were cited for all of the above, essentially. And the nice thing was the daughter worked in healthcare. So she was familiar with, hey, this shouldn't be happening. And the hospital even said, well, we don't think you should take her home. She's not ready to go home. Are you sure you wanna take care of her? You don't know what's going on with her. And it's like, yeah, I'll do a better job. So she did, both her and her mom filed a complaint and there was a subsequent follow-up. But yeah, they were cited on a lot of these and pretty much all of the above. So excellent, excellent. And anytime, by the way, folks, you have questions after the fact on this, or you think about it after, let Lindsay know. She'll get them to me and I'll follow up with Lindsay on them. Yep, absolutely. I did just post that final reminder there for you all in the chat. I hope after the conclusion of last week's part one of the series that you received the email the following day, and that same process will apply for tomorrow as well. So you should receive an email tomorrow morning. Just note that it will again, come from educationnoreplyatzoom.us. And that email will include a link to the recording of today's session. And then again, a link to the slides that Laura presented for us today. And that will include all of the additional resources that are in these slides as well. So you can just scan through to the back part of the slides if you're looking for those resources. And that link is there for you in the chat now as well. And as Laura mentioned, if you do have any questions, you can always reach out to us at educationatgha.org. And I'm happy to get those questions over to her. And she's always wonderful about being timely and very thorough in her responses. And it looks like Laura, that we did just have one question come in as we get ready to conclude here that asked, is it acceptable for the emergency department triage nurse to ask patients if they have any objections or exceptions to accepting blood or blood products if they may need them during their encounter? No, that's totally acceptable. Yeah. Now understand that order, the order of course for any blood has to come from the physician, the need, et cetera. But that's always a good heads up, given, do you have any objection? I would have the RN do that, not the admitting clerk because that's gotta be a clinical decision. But asking if they have an objection to receiving blood or blood products is totally okay. Perfect. Okay, wonderful. Well, I don't see any other pending questions. Thank you all so much for joining us today for part two. Thank you, Laura, as always for your time and information that you shared with us. And again, don't hesitate to reach out to us at educationatgha.org. And we look forward to having you all back with us next week for part three. I hope you have a wonderful afternoon. Thank you so much. Thanks everyone. Bye.

patient rights

hospital regulations

CMS deficiencies

safety

privacy

grievance handling

informed decision-making

risk management

patient safety

restraint and seclusion

legal compliance

medical records

staff training

CMS guidelines

Laura Dixon