HospitalInspections.org

Based on review of policies/procedures, medical records and interview with staff, it was determined the hospital failed to require that the use of restraints be in accordance with a written modification to the patient's plan of care for 1 of 1 patient (Pt #19).

Findings include:

Review of hospital policy titled Restraints, effective March 2008, revealed: "...Types of Restraints...Mitts...Side rails when used to restrict the patients' freedom to exit the bed...Documentation must include:...Written modification to the patients plan of care...."

Patient #19 was admitted to the hospital on 4/18/11 and is currently a patient at the facility .

According to nursing documentation, the patient was placed in x 3 or x 4 side rails and soft mittens as a restraint on 4/23/11 at 2000 hours. This was confirmed with the Director of Nursing (DON) on 4/27/11 at 1150 hours.

According to nursing documentation, the patient was placed in x 3 or x 4 side rails as a restraint on 4/24/11 at 2000 hours. This was confirmed with the DON on 4/27/11 at 1150 hours.

Patient #19's plan of care did not contain any mention of the patient's need for restraint.

The DON confirmed this on 04/27/11 at 1150 hours.

Based on review of policy, Medical Staff Rules and Regulations, and interview with staff, it was determined the hospital failed to require verbal orders, which include telephone orders, to be authenticated within 48 hours.

Findings include:

On 04/26/11, a review of the hospital policy titled Physician Orders # CSM 142, revised 3/11, revealed: "...All orders, including verbal orders, are dated, timed, and authenticated promptly. The following expectation is utilized to define 'promptly'...Verbal orders: Within 48 hours...Telephone and all other orders: Upon the next visit but not to exceed 7 days...."

The policy and Medical Staff Rules and Regulations do not meet the CMS regulation requirement for verbal orders (including telephone orders) to be authenticated within 48 hours.

On 4/27/11, the CEO and Chief Quality Officer confirmed that the content of the policy described above differentiates "verbal" and "telephone" orders. This differentiation is due to "inconsistent physician consultants" who may call in a telephone order but not actually be on site at the hospital to authenticate the order until several days later.

The policy/procedure does not meet the requirements of the regulation.