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Based on records reviewed and interviews, the Hospital failed for two of ten patients sampled (Patients #9 & #10) to ensure the use of restraint was ordered by a physician or other licensed independent practitioner.

Findings included:

The Hospital policy titled, Restraint for Adult and Pediatric Patients, dated 12/18/17, indicated the use of restraint required an order prior to application or in an emergency as soon as possible.

1.) The following regarding Patient #9.

The document titled, History & Physical, dated 7/13/17 at 7:33 P.M. indicated physicians admitted Patient #9 to the Hospital with a plan for cardiac surgery on 7/14/17.

The document titled, Physician's Orders, Documentation for Restraint, Seclusion of the Adult or Pediatric patient in Non-mental Health Settings, dated 7/14/17-7/15/17, indicated the Hospital restrained Patient #9 with wrist restraint of both wrists. The document indicated no documentation of a physician or other licensed independent practitioner order for use of restraint for the care of Patient #9.

The document titled, Restraint & Seclusion Events Reported, dated 1/1/17-1/1/18, indicated Patient #9 as restrained.

The Surveyor interviewed Risk Manager #1 on 2/17/18 (navigator of the electronic medical record for review). Risk Manager #1 said that Patient #9's medical record did not have an order for restraint.

The Hospital provided no documentation to indicate the use of restraint with the order of a physician or other licensed independent practitioner responsible for the care of Patient #9.

2.) The following regarding Patient #10.

The document titled, Restraint & Seclusion Events Reported, dated 1/1/17-1/1/18, indicated a patient in Labor & Delivery, Patient #10, as restrained, on 11/2/17.

Doctor's Orders, dated 11/2/17 regarding Patient #10, indicated no documentation of a doctor's order for restraint.

Risk Manager #1 said Patient #10's medical record had no documentation as restrained.

The Hospital provided no documentation to indicate the use of restraint with the order of a physician or other licensed independent practitioner responsible for the care Patient 10.

Based on records reviewed and interviews the Hospital failed for one of ten sampled patients (Patient #1) to ensure the Blood Bank provided services in accordance with the Hospital's policy regarding verbal orders.

Findings included:

The document titled, Supervisory Note, dated 5:14 P.M. on 11/25/17, indicated the Attending Trauma Surgeon accepted a severely injured and unstable patient (Patient #1) for direct transfer from an outside hospital by helicopter to the Hospital Operating Room. The Supervisory Note indicated the Trauma Surgeon activated the Massive Transfusion Protocol.

The Hospital policy titled, Massive Transfusion Protocol, dated 4/2014, indicated the Trauma (the term Trauma was undefined), EM (the abbreviation EM was undefined) or anesthesia physician activated the Massive Transfusion Protocol for the release of blood from the Blood Bank for life-threatening emergency. The policy indicated the physician communicates the need to activate the Massive Transfusion Protocol to the Charge Nurse.

The document titled, Anesthesia Record, dated from 12:30 P.M. through 1:30 P.M. on 11/25/17 indicated Patient #1 received 8242 milliliters (2.1 gallons) of blood products.

The Hospital policy titled, Patient Care Orders, dated 10/17/17, indicated the Hospital permitted verbal orders in emergent situations and when working under sterile conditions. The Policy indicated the individual receiving the verbal or telephone order was required to write down and "read back" the patient's name, date of birth and the complete order and the individual giving the verbal or telephone order will confirm that the information as correct. The Policy indicated verbal and telephone orders were authenticated by the prescribing practitioner within 24 hours. The Policy indicated verbal and telephone orders would include date, time, and practitioner's signature with printed name, credentials and their beeper or telephone number. The Policy indicated the Hospital permitted verbal and telephone orders to be given to Registered Nurses, Registered Pharmacists, Registered Respiratory Therapists, Registered Dieticians, Registered Physical Therapists and Registered Occupational Therapists. The Policy did not indicate that the Hospital permitted verbal or telephone orders to be given to Blood Bank personnel. The Policy did not indicate a procedure for verbal orders for blood products.

The document titled Massive Transfusion Protocol, Blood Product Release Authorization Form, dated 11/26/17, indicated only the first name person from the Operating Room requested blood. The Massive Transfusion Protocol, Blood Product Release Authorization form did not indicate:

1.) The individual receiving the verbal or telephone order was written down and "read back" the patient's name, and the complete order,

2.) The individual giving the verbal or telephone order will confirm that the information was correct,

3.) The time and practitioner's printed name with credentials with their beeper or telephone number,

4.) The Policy the verbal and telephone order was to be given to Registered Nurses, Registered Pharmacists, Registered Respiratory Therapists, Registered Dieticians, Registered Physical Therapists and Registered Occupational Therapists, or

5.) The person who received the verbal order, in accordance with Hospital policy.

The document titled, Massive Transfusion Protocol, Blood Product Release Authorization Form indicated the it was approved and current effective 3/10/12. The Hospital provided no documentation to indicate the Hospital revised or updated the Massive Transfusion Protocol, Blood Product Release Authorization form, as consistent with the Policies, Massive Transfusion Protocol Policy and the Patient Care Orders.

The email, dated at 1:56 P.M. on 2/16/18, indicated that the Massive Transfusion Protocol form, dated 3/10/12, was the most current edition.

The Surveyor interviewed Vice President #1 and Risk Manager #1 at 8:30 A.M. on 2/8/18. They said that the Massive Transfusion Protocol, Blood Product Release Authorization form, dated 11/26/17, was a verbal order to activate the Massive Transfusion Protocol. They said according to the documentation on this form, the Hospital was unable to identify who requested the activation of the Massive Transfusion Protocol. This was not consistent with the Hospital's Patient Care Orders policy.