HospitalInspections.org

Based on observation, staff interview, and review of clinical records and policies and procedures, it was determined that the hospital failed to protect and promote the rights of each patient. The hospital failed to ensure that orders for restraints were not written on an as-needed basis (refer to A169); failed to ensure that orders for restraints were renewed according to required time intervals (refer to A171); failed to ensure that restraints were used in accordance with a written modification to patients' plans of care (refer to A166); and failed to ensure that required documentation was in the medical records of patients who were restrained (refer to A184, A185, A186, A187, and A188).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on observations, interviews, and review of administrative and clinical records, the facility failed to appropriately modify the care plans of 5 of 8 sampled patients with restraints in a total sample of 20 patients in accordance with current federal regulations for restraint use when the care plans specified that restraints were to be used on an as-needed basis, a time-frame not allowable by current regulations (Patients 2, 4, 6, 11, and 19).

Findings:

1. On 2/22/10 at 2:23 PM, Patient 6 was observed lying in bed. Patient had her wrists tied to each side of her bed. A licensed staff sat next to Patient 6.

Review of the clinical records for Patient 6 on 2/22/10 revealed a 70- year-old female who was admitted to the facility with diagnoses including left lower lobe pneumonia, lower gastrointestinal bleed due to endometrial cancer (malignant tumor of the lining of the uterus).

During an interview with the licensed staff on the same day she stated that the patient is receiving intravenous fluids. Licensed staff also stated that the patient was combative and required the use of soft tie restraints bilaterally on her hands to prevent from her from pulling out her intravenous lines.

Further record review revealed a physician's order dated 2/19/10 for the application of bilateral wrist and ankle restraint ties "to maintain intravenous and oxygen source." The order specified the frequency and duration of the application of the restraints on as needed basis (PRN). A review of the care plan for Patient 6, dated 2/19/10, specified the frequency of the application of bilateral and or ankle restraints as "PRN/Q Shift."

Further record review revealed that Patient 6 was admitted from 10/20/09 through 10/22/09 and 10/2709 through 11/3/09 with the diagnosis of cellulitis of the buttock. Patient 6 had orders on both admissions for the application of bilateral wrist and ankle restraint ties. Both orders specified the frequency and duration of the application of the restraints on as needed basis (PRN). A review of the care plans for Patient 6 dated 10/20/09 and 11/3/09 specified the frequency of the application of bilateral and or ankle restraints as "PRN/Q Shift."

2. Review of clinical record for Patient 4 revealed a seventy two year old who was admitted to the facility on 10/29/09 through 11/3/09 and 01/28/10 through 02/03/10 and with diagnosis of aspiration pneumonia, Huntington's chorea, and profound mental retardation. Patient 4 had physician's orders on both admissions for the application of bilateral wrist and ankle restraint ties. Both orders specified that the wrist and ankle restraints are to be applied as needed (PRN) to maintain intravenous access. A review of the care plans for Patient 4 dated 10/29/09 and 1/28/10 specified the frequency of the application of bilateral and or ankle restraints as "PRN/Q Shift."

3. Review of clinical record for Patient 19 revealed a 39 year old who was admitted 12/22/2009 through 12/28/2009 with diagnosis of cellulitis of the arm. Patient 19 had an order for the application of bilateral wrist and ankle restraint ties. The order stated that the wrist and ankle restraints are to be applied as needed while on admission to the unit to maintain intravenous access, dressing and for healing. A review of the care plans for Patient 19, dated 10/29/09 and 1/28/10, specified the frequency of the application of bilateral and or ankle restraints as "PRN/Q Shift."



14907

4. Patient 2's admissions to the acute care unit included 4/15/09 and 11/17/09.

On 4/15/09, the patient had physician's orders for soft tie wrist restraints as needed (PRN) to maintain IV (intravenous line). This order was written for 4/15/09 through 4/22/09. Documentation in the Interdisciplinary Notes for this admission indicated that the restraints were initiated, discontinued, and restarted during the order period. The care plan, dated 4/15/09, documented the frequency of application of bilateral wrist and/or ankle restraints as "Q [every]Shift/PRN."

On 11/17/09, the patient again had physician's orders for "Restraints, Medical" for soft tie wrist restraints as needed (PRN) to maintain IV. This order was written for 11/17/09 through 11/24/09. Documentation in the Interdisciplinary Notes for this admission indicated that the restraints were initiated, discontinued, and restarted during the order period. The care plan, dated 11/17/09, documented the frequency of application of bilateral wrist and/or ankle restraints as "Q Shift/PRN", a time-frame not allowed by current regulations.

Facility Nursing Procedure No.38, titled "Restraints/Mechanical, Medical and Behavior, Management of," defined a "Mechanical Restraint" as "A procedure in which a person is restrained by a mechanical device such as soft ties ..." and specified that the physician's order "may not exceed 4 hours per incident."

During an interview on 2/24/10, licensed staff stated the care plan was written based on the physician's order.

Federal regulations do not allow orders for restraints to be written on an as needed or PRN basis and the patient's care plans were not in accordance with current regulations.

5. Patient 11 had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source. The orders were written for 6/11/09 through 6/15/09. The care plan, dated 6/11/09, documented the frequency of application of bilateral wrist and/or ankle restraints as "Q Shift/PRN", a time-frame not in accordance with regulatory requirements.

Patient 11 again had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source during an admission to the acute unit in December 2009. Interdisciplinary Notes dated 12/12/09 documented that the restraints were in use, discontinued, and restarted under the same physician's order. The care plan, dated 12/11/10, documented the frequency of application of bilateral wrist and/or ankle restraints as "Q 30 min/PRN", a time-frame not in accordance with regulatory requirements."

Facility Nursing Procedure No.38, titled "Restraints/Mechanical, Medical and Behavior, Management of," defined a "Mechanical Restraint" as "A procedure in which a person is restrained by a mechanical device such as soft ties ..." and specified that the physician's order "may not exceed 4 hours per incident."

During an interview on 2/24/10, licensed staff stated the care plan was written based on the physician's order.

Federal regulations do not allow orders for restraints to be written on an as needed or PRN basis and the patient's care plans were not in accordance with current regulations.

Based on observation, document review, and facility staff interviews, the facility failed to ensure that restraint orders are never written on an as needed basis, when 7 of 8 patients (Patients 2, 4, 6, 11, 13, 15, and 19) with restraints out of 20 sampled patients, had restraint orders written for an "as needed" basis.

Findings:

1. A review of Patient 15's medical record indicated that the patient was admitted to the acute care hospital unit from 3/17/09 - 4/08/09. During that admission, the patient had orders written for "Medical restraints, bilateral soft ties to wrists PRN (as needed) to maintain IV per plan." These orders were written for 3/3/09 through 3/10/09; 3/10/09 through 3/17/09; 3/19/09 through 3/26/09 and 4/2/09 through 4/9/09.

During an interview on 2/23/10 at 2:00 PM, direct care staff stated that restraints were applied and discontinued as needed based on patient behavior during the order period.


14907



2. Patient 2's admissions to the acute care unit included 4/15/09 and 11/17/09.

On 4/15/09, the patient had physician's orders for soft tie wrist restraints as needed to maintain IV. This order was written for 4/15/09 through 4/22/09. Documentation in the Interdisciplinary Notes for this admission indicated that the restraints were initiated, discontinued, and restarted as needed during the order period.

On 11/17/09, the patient again had physician's orders for "Restraints, Medical" for soft tie wrist restraints as needed to maintain IV. This order was written for 11/17/09 through 11/24/09. Documentation in the Interdisciplinary Notes for this admission indicated that the restraints were initiated, discontinued, and restarted as needed during the order period.

Facility Nursing Procedure No.38, titled "Restraints/Mechanical, Medical and Behavior, Management of," defined a "Mechanical Restraint" as "A procedure in which a person is restrained by a mechanical device such as soft ties ..." and specified that the physician's order "may not exceed 4 hours per incident."

During an interview on 2/23/10 at 2:00 PM, direct care staff stated that restraints were applied and discontinued as needed based on patient behavior during the order period.

3. Patient 11 had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source. The orders were written for 6/11/09 through 6/15/09.

Patient 11 again had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source during an admission to the acute unit in December 2009. Interdisciplinary Notes dated 12/12/09 documented that the restraints were in use, discontinued, and restarted under the same physician's order.

Patient 11 again had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source during an admission to the acute unit in January 2010. Interdisciplinary Notes documented the patient was in restraints from 1/13/10 through 1/14/10.

Facility Nursing Procedure No. 38, titled "Restraints/Mechanical, Medical and Behavior, Management of," defined a "Mechanical Restraint" as "A procedure in which a person is restrained by a mechanical device such as soft ties ..." and specified that the physician's order "may not exceed 4 hours per incident."

During an interview on 2/23/10 at 2:00 PM, direct care staff stated that restraints were applied and discontinued as needed based on patient behavior during the order period.



15261

4. On 2/22/10 at 2.23 PM, Patient 6 was observed lying in bed. Patient had her wrists tied to each side of her bed. A license staff sat next to Patient 6.

Review of the clinical records for Patient 6 on 2/22/10 revealed a 70-year-old female who was admitted to the facility with diagnoses including left lower lobe pneumonia and lower gastrointestinal bleed due to endometrial cancer (malignant tumor of the lining of the uterus).

Further record review revealed a physician's order dated 2/19/10 for the application of bilateral wrist and ankle restraint ties "to maintain intravenous and oxygen source." The order did not stipulate specific duration or time frame as to when the restraints could be applied, it only stated as needed.

Further record review revealed that Patient 6 was admitted from 10/20/09 through 10/22/09 and 10/27/09 through 11/3/09 with the diagnosis of cellulitis of the buttock. Patient 6 had an orders on both admission for the application of bilateral wrist and ankle restraint ties. The orders specified that the wrist and ankle restraints are to be applied as needed while on admission to the unit to maintain intravenous access.

5. Review of clinical record for Patient 4 revealed a 72-year-old who was admitted to the facility on 1/28/10 through 2/03/10 and 10/29/09 and 11/4/09 with diagnosis of aspiration pneumonia, Huntington's chorea, and profound mental retardation. Patient 4 had physician's orders on both admissions for the application of bilateral wrist and ankle restraint ties. The orders specified that the wrist and ankle restraints are to be applied as needed while on admission to the unit to maintain intravenous access.

6. Review of clinical record for Patient 19 revealed a 39-year-old who was admitted 12/22/09 through 12/28/09 with diagnosis of cellulitis of the arm. Patient 19 had an order for the application of bilateral wrist and ankle restraint ties. The order stated that the wrist and ankle restraints are to be applied as needed while on admission to the unit to maintain intravenous access, dressing and for healing.


14906



7. On 2/25/10, clinical record review for Patient 13 revealed that he had been admitted to the facility on 4/5/08 with diagnoses that included pneumonia and status post open cholecystectomy (gall bladder surgery). The physician ordered bilateral wrist and ankle restraints to maintain the integrity of the surgical wound held closed by staples. He wrote this order for medical restraints on 4/9/08 as "PRN" (as needed).

Based on facility staff interview and clinical record review, the facility failed to ensure that each restraint order did not exceed the 4-hour time limit renewal for 7 of 8 patients (Patients 2, 4, 6, 11, 13, 15, and 19) who had been placed in physical restraints out of a sample of 20. These patients had restraint orders for time periods exceeding 4 hours.

Findings:

1. On 2/25/10 clinical record review for Patient 13 revealed that he had been admitted to the facility on 4/5/08 with diagnoses that included pneumonia and status post open cholecystectomy (gall bladder surgery). The physician ordered bilateral wrist and ankle restraints to maintain the integrity of the surgical wound held closed by staples. He wrote this order for medical restraints PRN (as needed) to begin on 4/9/08 at 14:32 (2:42 PM) and to end 4/10/08 at 8:56 AM. This was a duration of 19 hours and 28 minutes, exceeding the 4-hour renewal limit.

This order was acknowledged by facility administrative staff on 2/25/10 at 1:20 PM.




14907

2. Patient 2's admissions to the acute care unit included admission dates of 4/15/09 and 11/17/09.

On 4/15/09, the patient had physician's orders for soft tie wrist restraints as needed (PRN) to maintain IV (intravenous line.) This order was written for 4/15/09 through 4/22/09. There was no documentation that the order was renewed by the physician every 4 hours.

On 11/17/09, the patient again had physician's orders for "Restraints, Medical" for soft tie wrist restraints as needed to maintain IV. This order was written for 11/17/09 through 11/24/09. There was no documentation that the order was renewed by the physician every 4 hours.

During an interview on 2/23/10 at 2:00 PM, direct care staff stated that restraints were applied and discontinued based on patient behavior during the entire length of the order period.

3. Patient 11 had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source. The orders were written for 6/11/09 through 6/15/09.

Patient 11 again had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source during an admission to the acute unit in December 2009.

Patient 11 again had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source during an admission to the acute unit in January 2010. Interdisciplinary Notes documented the patient was in restraints from 1/13/10 through 1/14/10.

There was no documented evidence that the physician had renewed the restraint order every 4 hours.

On 2/25/10 at 10:00 AM, licensed staff acknowledged the duration of the order.



15261

4. Review of the clinical records for Patient 6 on 2/22/10 revealed a 70-year-old female who was admitted to the facility with diagnoses including left lower lobe pneumonia and lower gastrointestinal bleed due to endometrial cancer ( tumor in the lining of the uterus).

Further record review revealed a physician's order dated 2/19/10 for the application of bilateral wrist and ankle restraint ties "to maintain intravenous and oxygen source." The order did not stipulate specific duration time frame as to when the restraints could be applied; it only specified as needed (PRN).

Further record review revealed that Patient 6 was admitted from 10/20/09 through 10/22/09 and 10/27/09 through 11/3/09 with the diagnosis of cellulitis of the buttock. Patient 6 had orders on both admissions for the application of bilateral wrist and ankle restraint ties. The orders specified that wrist and ankle restraints are to be applied as needed while on admission to the unit to maintain intravenous access.

5. Review of clinical record for Patient 4 revealed a seventy-two-year-old who was admitted to the facility on 10/29/09 through 11/4/09 and 1/28/10 through 2/03/10 with diagnosis of aspiration pneumonia, Huntington's chorea, and profound mental retardation. Patient 4 had physician's orders on both admission for the application of bilateral wrist and ankle restraint ties. The order specified that the wrist and ankle restraints were to be applied as needed while on admission to the unit to maintain intravenous access.

6. Review of clinical record for Patient 19 revealed a 39-year-old who was admitted 12/22/09 through 12/28/09 with diagnosis of cellulitis of the arm. Patient 19 had an order for the application of bilateral wrist and ankle restraint ties. The order specified that the wrist and ankle restraints were to be applied as needed while on admission to the unit to maintain intravenous access, dressing and for healing.



22327

7. A review of Patient 15's chart indicated that the patient was admitted on 3/3/09 with diagnoses of pneumonia, dehydration, and urinary tract infection. The patient was receiving IV (Intravenous) antibiotics and fluids to treat his symptoms. On 3/3/09, the physician ordered "Medical restraints PRN (as needed) soft ties to wrists to maintain IV". The patient required the medical restraints so that he would not inadvertently remove the IV. There were also orders written on 3/10/09, 3/19/09, and 4/2/09 for PRN medical restraints. All of these orders were written for durations of seven days, much longer than the four hours allowed by the regulation.

Facility staff acknowledged the duration of the orders on 2/24/10 at 2:15 PM.

Based on interview, clinical record review, and policy and procedure review, the hospital failed to ensure that a face-to-face evaluation was performed within one hour of the initiation of restraints when 6 of 8 patients with restraints did not have documented evidence of this evaluation within one hour of each initiation of restraints by the physician, other licensed independent practitioner, or authorized registered nurse (Patients 2, 4, 6, 11, 15, and 19).

Findings:

1. Patient 2's admissions to the acute care unit included 4/15/09 and 11/17/09.

On 4/15/09, the patient had physician's orders for soft tie wrist restraints as needed (PRN) to maintain IV (intravenous line) This order was written for 4/15/09 through 4/22/09. Documentation in the Interdisciplinary Notes for this admission indicated that the restraints were initiated, discontinued, and restarted during the order period. There was no evidence that a face-to-face evaluation documenting the patient's immediate situation, the patient's medical and behavioral condition, and the need to continue or terminate the restraint was performed prior to each application of restraints.

On 11/17/09, the patient again had physician's orders for "Restraints, Medical" for soft tie wrist restraints as needed to maintain IV. This order was written for 11/17/09 through 11/24/09. Documentation in the Interdisciplinary Notes for this admission indicated that the restraints were initiated, discontinued, and restarted during the order period.

Facility Nursing Procedure No. 38, titled "Restraints/Mechanical, Medical and Behavior, Management of," defined "soft ties" as a mechanical restraint and specified that the "HSS[Health Services Specialist]... must assess the client within 55 minutes." There was no evidence that this face-to-face assessment documenting the patient's immediate situation, the patient's medical and behavioral condition, and the need to continue or terminate the restraint was performed prior to each application of restraints.

2. Patient 11 had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source. The orders were written for 6/11/09 through 6/15/09.

Patient 11 again had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source during an admission to the acute unit in December 2009. Interdisciplinary Notes dated 12/12/09 documented that the restraints were in use, discontinued, and restarted under the same physician's order.

Patient 11 again had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source during an admission to the acute unit in January 2010. Interdisciplinary Notes documented the patient was in restraints from 1/13/10 through 1/14/10.

Facility Nursing Procedure No. 38, titled "Restraints/Mechanical, Medical and Behavior, Management of," defined "soft ties" as a mechanical restraint and specified that the "HSS... must assess the client within 55 minutes." There was no evidence that this face-to-face assessment documenting the patient's immediate situation, the patient's medical and behavioral condition, and the need to continue or terminate the restraint was performed prior to each application of restraints.

On 2/25/10 at 10:00 AM, administrative staff confirmed the documentation was not in the record.



15261

3. Review of the clinical records for Patient 6 on 2/22/2010 revealed a 70-year-old female who was admitted to the facility with diagnoses including left lower lobe pneumonia and lower gastrointestinal bleed due to endometrial cancer (tumor in the lining of the uterus).

Further record review revealed a physician's order dated 2/19/10 for the application of bilateral wrist and ankle restraint ties "to maintain intravenous and oxygen source." The order did not stipulate specific duration time frame as to when the restraints could be applied. It only stated as and when necessary.

Review of the clinical records for Patient 6 did not show that a face to face evaluation that included a complete assessment of the patient's condition within an hour after the restraints were applied was completed.

Further record review revealed that Patient 6 was admitted from 10/20/2009 through 10/22/2009 with the diagnosis of cellulitis of the buttock. Patient 6 had an order for the application of bilateral wrist and ankle restraint ties. The order stated that the wrist and ankle restraints are to be applied as needed while on admission to the unit to maintain intravenous access.

Review of the clinical records for Patient 6 did not show that a face to face evaluation that included a complete assessment of the patient's condition within an hour after the restraints were applied.

Further record review revealed that Patient 6 was admitted from 10/27/09 through 11/03/09 with the diagnosis of cellulitis of the buttock. Patient 6 had an order for the application of bilateral wrist and ankle restraint ties. The order stated that the wrist and ankle restraints are to be applied as needed while on admission to the unit to maintain intravenous access.

Review of the clinical records for Patient 6 did not show that a face to face evaluation that included a complete assessment of the patient's condition within an hour after the restraints were applied.

4. Review of clinical record for Patient 4 revealed a seventy-two-year-old who was admitted to the facility on 1/28/2010 through 2/03/2010 with diagnosis of aspiration pneumonia, Huntington's chorea, and profound mental retardation. Patient 4 had an order for the application of bilateral wrist and ankle restraint ties. The order stated that the wrist and ankle restraints are to be applied as needed while on admission to the unit to maintain intravenous access.

Review of the clinical records for Patient 4 did not show that a face to face evaluation that included a complete assessment of the patient's condition within an hour after the restraints were applied.

Review of clinical record for Patient 4 revealed a 72-year-old who was admitted to the facility on 10/29/09 through 11/04/09 with diagnosis of aspiration pneumonia, Huntington's chorea, and profound mental retardation. Patient 4 had an order for the application of bilateral wrist and ankle restraint ties. The order stated that the wrist and ankle restraints are to be applied as needed while on admission to the unit to maintain intravenous access.

Review of the clinical records for Patient 4 did not show that a face to face evaluation that included a complete assessment of the patient's condition within an hour after the restraints were applied.

5. Review of clinical record for Patient 19 revealed a 39 year old who was admitted 12/22/09 through 12/28/09 with diagnosis of cellulitis of the arm. Patient 19 had an order for the application of bilateral wrist and ankle restraint ties. The order stated that the wrist and ankle restraints are to be applied as needed while on admission to the unit to maintain intravenous access, dressing and for healing.

Review of the clinical records for Patient 19 did not show that a face to face evaluation that included a complete assessment of the patient's condition within an hour after the restraints were applied was completed.



22327

6. A review of the Patient 15's medical record indicated that the patient was admitted on 3/3/09 with diagnoses of pneumonia, urinary tract infection, and dehydration. The patient received IV (intravenous) fluids and IV antibiotics to fight the infections and resolve the dehydration.

Physician orders for medical restraints, in the form of soft ties to wrists, PRN (as needed) to maintain IV were written on 3/3/09, 3/10/09, 3/19/09 and 4/2/09. A review of the interdisciplinary notes dated 3/10/09 at 4:30 AM indicated that medical restraints were applied to the patients wrists to assist in maintaining the IV site. On 3/10/09 at 9:10 AM, there was documentation of the restraints again being on the patient.

On 4/2/09 at 9:05 AM, there was documentation that the patient's restraints were renewed but there was no documentation of any face to face evaluation for the behavior leading to the use of the restraints.

There is no evidence in the patient's medical record that a face to face evaluation documenting the patient's immediate situation, the patient's medical and behavioral condition and the need to continue or terminate the restraints was performed prior to the application of the restraints.

See A188 below.

See A188 below.

See A188 below.

Based on patient record review and interview, the hospital failed to ensure adequate documentation in the patient medical record when 3 of 8 patients with restraints did not have documentation of a description of the patient's behavior and intervention used; alternative or less restrictive interventions attempted; the patient's condition or symptom(s) that warranted the use of restraints; and the patient's response to the intervention used, including the rationale for continued use of the restraint (Patients 2, 11 and 15).

Findings:

1. Patient 2's admissions to the acute care unit included admission dates of 4/15/09 and 11/17/09.

On 4/15/09, the patient had physician's orders for soft tie wrist restraints as needed (PRN) to maintain IV (intravenous line.) This order was written for 4/15/09 through 4/22/09. Documentation in the Interdisciplinary Notes for this admission indicated that the restraints were initiated, discontinued, and restarted during the order period. There was no documentation of a description of the patient's behavior and intervention used; alternative or less restrictive interventions attempted; the patient's condition or symptom(s) that warranted the use of restraints; and the patient's response to the intervention used, including the rationale for continued use of the restraint.

On 11/17/09, the patient again had physician's orders for "Restraints, Medical" for soft tie wrist restraints as needed to maintain IV. This order was written for 11/17/09 through 11/24/09. Documentation in the Interdisciplinary Notes for this admission indicated that the restraints were initiated, discontinued, and restarted during the order period. There was no documentation of a description of the patient's behavior and intervention used; alternative or less restrictive interventions attempted; the patient's condition or symptom(s) that warranted the use of restraints; and the patient's response to the intervention used, including the rationale for continued use of the restraint.

2. Patient 11 had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source. The orders were written for 6/11/09 through 6/15/09.

Patient 11 again had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source during an admission to the acute unit in December 2009. Interdisciplinary Notes dated 12/12/09 documented that the restraints were in use, discontinued, and restarted under the same physician's order.

There was no documentation of a description of the patient's behavior and intervention used; alternative or less restrictive interventions attempted; the patient's condition or symptom(s) that warranted the use of restraints; and the patient's response to the intervention used, including the rationale for continued use of the restraint.

Patient 11 again had physician's orders for bilateral soft tie wrist and ankle restraints as needed to maintain IV and oxygen source during an admission to the acute unit in January 2010. Interdisciplinary Notes documented the patient was in restraints from 1/13/10 through 1/14/10. There was no documentation of a description of the patient's behavior and intervention used; alternative or less restrictive interventions attempted; the patient's condition or symptom(s) that warranted the use of restraints; and the patient's response to the intervention used, including the rationale for continued use of the restraint.

During an interview on 2/25/10 at 10:00 AM, administrative staff confirmed that the documentation was not in the record.



22327

3. A review of Patient 15's chart indicated that the patient was admitted to the acute hospital with diagnoses of pneumonia, dehydration and urinary tract infection on 3/3/09. The patient had physician's orders for medical restraints, bilateral soft ties to wrists, PRN (as needed) to maintain the IV (intravenous) line written on 3/3/09, 3/10/09, 3/19/09, and 4/08/09. A review of the ID (Interdisciplinary) Notes on those dates indicated that there was no documentation of the patient's behavior requiring the restraint and the intervention used; alternative or less restrictive interventions attempted, or the patient's response to the interventions used.

Based on interview and record review, the hospital failed to analyze aspects of performance that assess processes of care when it failed to ensure that restraint practices were in accordance with current regulations.

Findings:

During record reviews of Patients 2, 4, 6, 11, 13, 15, and 19, physician's orders were found for restraints to be used on an as-needed basis, with no time limits specified, and with the orders being in effect for 5 to 7 days.

During interviews on 2/23/10 and 2/25/10, staff stated the restraints were placed and removed based on the patients' behaviors during the restraint order periods.

Nursing Procedure No. 38, "Restraints/Mechanical, Medical and Behavior, Management of," specified that physician's orders for medical restraints was "good for 7 days."

On 2/24/10, administrative staff stated the facility was unaware that current federal regulations do not allow restraint orders on an as-needed basis or that orders must be written for each application of restraints.

The minutes for the various quality assessment and performance improvement committees were reviewed. There was no documentation that the facility's restraint policies and procedures had been revised based on changing regulations.

On 2/25/10 at 3:30 PM, administrative staff responsible for the facility's Quality Assessment and Performance Improvement program were interviewed. They identified several methods for the facility to ensure it had up-to-date regulations but confirmed that they were unaware of the change in the regulations regarding restraint use.

Based on document review and interview, the facility failed to describe the organization of the medical staff in its medical staff by-laws when there was no documentation of who was responsible for reviewing and evaluating the clinical work of the medical staff.

Findings:

A review of the medical staff by-laws on 2/23/10 showed that there was no description of who is responsible to review and evaluate the clinical work of the medical staff.

In an interview with the Medical Staff Secretary on 2/23/10 at 10:00 AM, she acknowledged that the description of who is responsible for reviewing and evaluating the clinical work of the medical staff was not in the by-laws.

Based on observation and interview, the facility failed to ensure that a medication was prepared and administered in accordance with accepted standards of practice, when a nurse held a syringe of medication in her mouth during verification of the medication order and prior to administering the medication to the patient.

Findings:

On 2/24/10 at 8:45 AM, while observing an unsampled patient receiving pre-procedural sedation of Versed 5 mg. per IM (intramuscular) injection, the nurse preparing the medication held the filled, capped syringe in her mouth while verifying the medication in the patient's medical record and while walking over to the patient to administer the medication.

A review of the nurse's training records indicated that she had received training in infection control procedures and medication administration within the last year.

In an interview with the nurse on 2/24/10 at 8:50 AM, she acknowledged that she should not have put the syringe in her mouth and that this did not meet infection control standards.

Accepted standards of practice for nursing care of patients dictate that nurses provide care in a safe and appropriate manner. Holding a prepared syringe in one's mouth during order verification and prior to administration of the medication to the patient does not meet that standard for nursing care or infection control.

Based on record review and interview, the hospital failed to ensure that verbal orders were used infrequently when the majority of physician's orders in the hospital's computerized order system were entered by staff other than the ordering physician for 11 of 20 sampled patients (Patients 2, 3, 4, 5, 7, 9, 11, 14, 15, 16, and 17).

1. The medical record for Patient 2 was reviewed on 2/24/10. The computer printout of the physician's orders for 4/19/09, 11/17/09, 1/15/10, and 2/2/10 documented that all orders were placed by non-physician staff members then later authenticated by the physician.

2. The closed medical record for Patient 11 was reviewed on 2/24/10. The computer printout of the physician's orders for 6/11/09 and 12/12/09 documented that the orders were placed by non-physician staff members then later authenticated by the physician.

3. The closed medical record for Patient 14 was reviewed on 2/24/10. The computer printout of the physician's orders for 1/15/10 documented that the orders were placed by non-physician staff members then later authenticated by the physician.

During an interview at 2/24/10, licensed staff stated that the majority of physician orders were entered into the computer by staff other than the physician.



22327

4. A review of the medical record for Patient 3 indicated that he was admitted on 1/27/10 with the diagnoses of vomiting, gastrointestinal bleeding, anoxic brain damage, and severe mental retardation. A review of the computer generated order sheet for 1/28/10 showed the patient had twelve separate orders entered by a staff member other than the physician.

5. A review of the medical record for Patient 15 indicated that the patient was admitted on 3/3/09 with diagnoses of pneumonia, dehydration, and urinary tract infection. A spot check review of the computer generated order sheet for 3/3/09 showed that there were four orders entered by someone other than the ordering physician; there was one order on 3/10/09, 3/19/09 and 3/23/09. There were two orders on 3/30/09, one on 4/2/09 and two on 4/3/09 that were entered by someone other than the ordering physician.

6. A review of the medical record for Patient 16 indicated that he was admitted on 2/1/10 with diagnoses of gastrointestinal bleeding and diabetes. A review of the computer generated order sheet for 2/1/10 showed that there were 20 orders entered by someone other than the ordering physician; on 2/2/10 there were 13 orders and on 2/3/10 there were four orders entered by someone other than the ordering physician.

7. A review of the medical record for Patient 17 indicated that he was admitted on 12/9/09 with a diagnosis of pneumonia. A spot check review of the computer generated order sheet showed that the patient had 11 orders entered by someone other than the ordering physician on 12/9/09; on 12/14/09 he had 5 orders; on 12/16/09 he had five orders entered and on 12/19/09 he had five orders entered by someone other than the ordering physician.

Facility management staff stated in an interview on 2/24/10 at 2:00 PM, that orders are considered as verbal orders when they are entered on the computer generated order sheets by a person other than the ordering physician.


14906



8. A review of the medical record for Patient 7 revealed that she was admitted on 12/9/09 with diagnoses that included epilepsy and recurrent pneumonia. A review of the computer generated order sheet for 12/9/09 showed that there were 8 orders entered by someone other than the ordering physician; on 12/13/09 there was 1 order; on 12/16/09 there were 4; on 12/21/09 there were 2; on 12/2309 there were 2; on 12/28/09 there was 1 and on 12/30/09 there were 3 orders entered by someone other than the ordering physician.

9. A review of the medical record for Patient 9 revealed that he was admitted on 11/20/09 with diagnoses that included chronic obstructive pulmonary disease and fever not otherwise specified. A review of the computer generated order sheet for 11/20/09 showed that there were 5 orders entered by someone other than the ordering physician and on 11/21/09 there were 2 orders.

In an interview with facility management staff on 2/24/10 at 2:00 PM, it was clarified by them that it is a verbal order when there is documentation on the computer generated order sheets that a person, other than the ordering physician, enters the order.



15261

10. Review of the clinical records for Patient 4 on 02/23/10 at 9 AM., revealed a 72-year-old who was admitted to the facility on 02/21/10 with diagnosis including aspiration pneumonia and Huntington's chorea. Further record review revealed that on 02/22/10 at 9:40 AM a verbal order stating "resume usual diet and decrease water flushes to 60 cc." The order instructed licensed staff to reduce the intravenous rate to 40 cc per hour. The order was recorded in the patients clinical records on a page titled "New ER 2000 Physicians Orders"; there was no notation as to the title of the staff receiving the orders.

During interview the same day the Administrative staff stated that the "New ER 2000 Physician Orders" was a work sheet that was removed from the clinical records after the page data has been entered into the computer system.

11. Review of the clinical record for Patient 5 on 02/23/10 at 9:30 AM, revealed a 58-year-old admitted to the facility on 01/10/10 with diagnoses that include pneumonia, history of bronchitis. Further record review revealed the following:

A. 02/11/10 at 9:15 AM, a verbal order for "BNP today"
B. 02/12/10 at 4:05 AM, verbal orders for "Chest x-ray Tuesday 02/16/10" and "Decrease intravenous fluid rate to 20 cc per hour".
C. 02/24/10 at 7:00 PM, a verbal order to "hold breakfast, nothing to eat by mouth after midnight until after lab draw"
D. 02/25/10 at 12:30 PM a verbal order to "inject furosemide 40 mg intravenously once"

There was no notation as to the title of the staff receiving the orders. During interview the same day the Administrative staff stated that the "New ER 2000 Physician Orders" was a work sheet that was removed from the clinical records after the page data has been entered into the computer system.

Based on document review and interview, the facility failed to ensure that verbal orders were accepted only by persons authorized to do so by hospital policy and Federal and state laws when verbal orders were taken on the "ER 2000 Physician's Orders" sheets and were not dated, timed, or signed by the person receiving the orders of 4 of 20 sampled patients (Patients 3, 4, 5, and 11).

Findings:

1. A review of Patient 3's medical record indicated that the patient was admitted to the acute hospital unit on 1/27/10 with diagnoses vomiting and gastrointestinal bleeding. The patient had orders written on the "New ER 2000 Physician Orders" sheet for 1/29/10, 2/5/10, 2/8/09, 2/11/10 and for an unknown date and time under a lab order written and signed by the physician on 2/16/10. There also were orders on these sheets written and signed by the physician. The orders referenced above were in a handwriting different from the physician's noted on the order sheet. There was no physician signature for any of these orders and no signature or title of the person writing the verbal orders.

On 2/24/10, a review of the Nursing Procedure No. 7, dated 10/8/09, indicated that "for handwritten verbal/telephone orders received from a physician, the licensed nursing personnel receiving the order will: write the order exactly as it is received...; how the order was received (e.g. verbal order (VO), telephone order (TO); physician's name/nursing person's name and title; ...write the date, exact time order received..."

In an interview with the Senior RN on the unit on 2/23/10 at 11:00 AM, she stated that the "ER 2000 Physician's Orders" sheets were worksheets, not really order sheets. She stated that is why the orders were not signed by whoever received those orders. She stated that all the physician orders are written into the ER 2000 and that the night shift audited the charts daily to make sure that all new orders are entered into the program. The Senior RN was unable to produce any policy or procedure regarding the use of the worksheet. She did acknowledge that the physician did date, time and sign all of the orders that he wrote on the worksheet, as if he was writing orders. She also acknowledged how the use of this worksheet could lead to confusion as to what were verbal orders and what had been entered into the computer program for physician's orders.



14907

2. During review of the medical record for Patient 11 on 2/24/10, four pages of handwritten orders were found on the "NEW ER 2000 PHYSICIAN'S ORDERS" sheets. Each of these orders was dated and timed. For 12 of the 22 separately dated and timed orders, which included intravenous therapy and medications, lab tests, and transfer orders, there was no signature or title of the person writing the verbal orders.

A review of the Nursing Procedure No. 7, dated 10/8/09, indicated that "for handwritten verbal/telephone orders received from a physician, the licensed nursing personnel receiving the order will: write the order exactly as it is received...; how the order was received (e.g. verbal order (VO), telephone order (TO); physician's name/nursing person's name and title; ...write the date, exact time order received..."

In an interview with the Senior RN on the unit on 2/23/10 at 11:00 AM, she stated that the "ER 2000 Physician's Orders" sheets were worksheets, not really order sheets. She stated that is why the orders were not signed by whoever received those orders. She stated that all the physician orders are written into the ER 2000 and that the night shift audited the charts daily to make sure that all new orders are entered into the program. The Senior RN was unable to produce any policy or procedure regarding the use of the worksheet. She did acknowledge that the physician did date, time and sign all of the orders that he wrote on the worksheet, as if he was writing orders. She also acknowledged how the use of this worksheet could lead to confusion as to what were verbal orders and what had been entered into the computer program for physician's orders.



15261

3. Review of the clinical records for Patient 4 on 02/23/2010 at 9 AM, revealed a 72-year-old who was admitted to the facility on 02/21/2010 with diagnosis including aspiration pneumonia and Huntington's chorea. Further record review revealed a verbal order on 02/22/2010 at 9:40 AM to "resume usual diet and decrease water flushes to 60 cc." The order also instructed licensed staff to reduce the intravenous rate to 40 cc per hour. The order was recorded in the patient's clinical record on a page titled "New ER 2000 Physicians Orders" there was no notation as to the title of the staff receiving the orders.

During interview the same day the Administrative staff stated that the "New ER 2000 Physician Orders" was a work sheet that was removed from the clinical records after the page data has been entered into the computer system.

4. Review of the clinical record for Patient 5 on 02/23/2010 at 9:30 AM, revealed a 58-year-old admitted to the facility on 01/10/2010 with diagnoses that include pneumonia, history of bronchitis. Further record review revealed:

A. 02/11/2010 at 9:15 AM, a verbal order for "BNP today"
B. 02/12/2010 at 4:05 AM, a verbal order for "Chest x-ray Tuesday 02/16/2010" and "Decrease intravenous fluid rate to 20 cc per hour"
C. 02/24/2010 at 7:00 PM, a verbal order to "hold breakfast, nothing to eat by mouth after midnight until after lab draw"
D. 02/25/2010 at 12:30 PM a verbal order to "inject furosemide 40 mg intravenously once"

There was no notation as to the title of the staff receiving the orders. During interview the same day the Administrative staff stated that the "New ER 2000 Physician Orders" was a work sheet that was removed from the clinical records after the page data has been entered into the computer system.

Based on facility staff interview and clinical record review, the facility failed to ensure that verbal orders were authenticated within 48 hours for 9 of 20 sampled Patients (Patients 2, 5, 7, 9, 11, 14, 15, 17 and 19).

Findings:

1. A review of the medical record for Patient 9 revealed that he was admitted on 11/20/09 with diagnoses that included chronic obstructive pulmonary disease and fever not otherwise specified. A review of the computer generated order sheet for this hospital stay revealed 6 physicians's orders that had not been authenticated within 48 hours.

2. A review of the medical record for Patient 7 revealed that she was admitted on 12/9/09 with diagnoses that included epilepsy and recurrent pneumonia. A review of the computer generated order sheet for this hospital stay revealed 2 physicians's orders that had not been authenticated within 48 hours.



22327

3. A review of Patient 15's medical record indicated that he was admitted on 3/3/09 with diagnoses of pneumonia, dehydration, and urinary tract infection. A review of the computer generated physician's order sheet indicated that five physician's orders were not authenticated within the 48 hour time frame as per the regulation.

4. A review of Patient 17's medical record indicated that the patient was admitted on 12/9/09 with a diagnosis of pneumonia. A review of the computer generated physician's orders indicated that 12 physician's orders were not authenticated within the 48 hour time frame as per the regulation.



14907

5. During review of the medical records for Patients 2, 11, and 14, multiple verbal orders were identified as not being authenticated within 48 hours.

This was confirmed by licensed staff during review of the physician's orders on the computer system.



15261

6. Review of the clinical record for Patient 5 on 02/23/10 at 9:30 AM, revealed a 58 year old admitted to the facility on 01/10/10 with diagnoses that include pneumonia, history of bronchitis. Further record review revealed that on:


A. 02/19/10 at 6:33 PM, the attending physician ordered methylprednisolone sodium succinate (a steroid medication used for respiratory conditions). The order was not authenticated until 02/24/10.
B. 02/19/10 at 12 PM, the attending physician ordered furosemide 20 mg by mouth once a day, the order was not authenticated until 02/24/10.

During interview with administrative staff on the same day, it was stated that order should have been authenticated within the stipulated policy of 48 hours.

7. Review of the clinical record for Patient 19 on 02/23/10 at 10 AM, revealed a 39 year old who was admitted 12/22/09 through 12/28/09 with diagnosis of cellulitis of the arm. Further record review revealed that on:

A. 12/22/09 at 2:35 PM, the attending physician ordered citrate of magnesia 10 ounces by mouth once, the order was not authenticated until 12/28/2009.
B. 12/22/09 at 2:35 PM, the attending physician ordered wet to dry dressing daily, the order was not authenticated until 12/28/2009.
C. 12/22/09 at 4:19 PM, the attending physician ordered to continue all previous orders, the order was not authenticated until 12/28/09.
D. 12/22/09 at 2:16 PM, the attending physician ordered a urinalysis once; the order was not authenticated until 12/28/09.
E. 12/22/09 at 2:09 PM, the attending physician ordered intravenous fluid of dextrose normal saline at a rate of 100 cc per hour via intravenous line; the order was not authenticated until 12/28/09.
F. 12/22/09 at 2:08 PM, the attending physician ordered Vancomycin 1 gram intravenously every 12 hours, the order was not authenticated until 12/28/09.
G. 12/22/09 at 4:03 PM, the attending physician ordered Ceftriaxone 1 gram in D5W 50 ml intravenously every day, the order was not authenticated until 12/28/09.
H. 12/22/09 at 1:50 PM, the attending physician ordered admission to the facility, the order was not authenticated until 12/28/09.

Based of observation, interview, and manufacturer's specification, the facility failed to store medication to maintain optimal potency and effectiveness for 2 of 6 sampled patients (Patients 1 and 4).

Findings:

On 2/22/10 at 3:30 PM, two opened containers of calcitonin nasal spray were observed to be stored in a hallway medication cart while lying on their sides. One was labeled for Patient 1's use and one for Patient 4. Calcitonin nasal spray is used to treat osteoporosis (fragile bones) and is to always be stored in an upright position after opening to maintain dosage effectiveness.

At the time of discovery, the staff nurse who accompanied the surveyor stated that she wasn't aware that storage of calcitonin on it's side was a problem. She acknowledged that it was after reading the upright storage requirements on the boxes of calcitonin.

Based on observation and facility staff interview, the facility failed to label six intravenous solution antibiotic containers with identifiable expiration dates.

Findings:

On 2/22/10 at 3:15 PM, six bags of antibiotic intravenous fluids were observed in the W1 Unit medication refrigerator. There were three thawed bags of Cefazolin that documented they were good for 30 days after thaw and had a stick on label that documented, "2/18/10 CRS." There were also three thawed bags of ceftriaxone that documented they were good for 21 days after thaw that had a stick on label as follows,"2/19/09 CRS".

The staff nurse who accompanied the surveyor stated that she was not sure if the dates were expiration dates or thawed dates. She also didn't know what the letters "CRS" meant.

On 2/24/10 at 9:00 AM the Chief of Pharmacy was interviewed. He stated that the dates on the labels were thaw dates and that the letters were the initials of the individual pharmacist who had thaw the product. He acknowledged that there was no way to determine this by reading the labels such as they were.

Based on facility staff interview and facility policy and procedures (P&P) review, the facility's P&P for the examination of tissue samples did not specify which would require microscopic, macroscopic, or both.

Findings:

On 2/23/10, the facility's P&P for tissue samples was reviewed. It did not contain any information regarding which would require microscopic, macroscopic, or both.

On that same day at 1:45 PM, facility administrative staff stated that their pathologist was on contract service; consequently that component was not in the facility's P&P. The surveyor stated that if the contract pathologist had tissue examination specifics that the facility medical staff had agreed to, that would meet the regulatory requirement. She stated that the pathologist did not have differential tissue examination requirements.

Based on observation and facility staff interview, the facility failed to employ effective infection control techniques during the packaging of oral medications and the storage of clean intravenous pumps.

Findings:

1. On 2/24/10 at 9:10 AM during observation of the unit dose pharmacy, a pharmacy technician was using a automated packaging machine to prepare oral medications. The machine packaged the medication in individual cellophane-like plastic pouches that were connected to each other and came out of the machine in a long strip. As the strip came out of the machine it collected on the bare floor. The pharmacy technician would roll up the packaged medication dragging them on the floor as she did so. When asked why these medication packages were allowed to drag on the floor, she grabbed a basket from the other side of the machine and let the packages collect in the basket rather than the floor. She stated that that was the purpose of the basket but offered no explanation as to why she had not been using it.

2. On 2/22/10 at 3:30 PM in a utility room of Unit W1, a bin of dirty laundry was stored approximately three feet away from clean intravenous pumps ready for use.

At the time of discovery the staff nurse accompanying the surveyor acknowledged the potential for contamination.