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Based on the review of medical records, it was determined that in two of two medical records in which documentation reflects the use of restraints for medical surgical purposes, medical records # 2 and 10, the hospital failed to ensure that the CAH's health care services were furnished in accordance with written policies. Findings:

The following policy was reviewed: Patient Care Policy Number SR PTC 13 entitled Restraints in the Acute Medical and Surgical Care. The policy states the following: Continued Use of Restraint: Continued use of restraint beyond the first 24 hours is : "Renewed or a new order written once each calendar day".
The policy also states the following: Content of Restraint Order: "An order for patient restraint will contain: The type of restraint (physical and/or chemical); Reason for restraint; and Criteria for release".

The review of medical records revealed that the hospital had developed a form entitled Physician Practitioner Orders Restraint & Management of the Confused or Severely Agitated Patient. The form contained the following direction to staff: "All Boxed Orders Require Practitioner Check to be Initiated". The following areas were identified and "boxed" on the form and required a checkmark or a practitioner's signature with date/time in the box: Nursing Assessment; The Following Risks (for harm) are Present; Alternative Interventions Attempted or Considered; Type of Restraint Used; Statement "I concur with the above assessment"; Criteria for Release; and Medications.

Medical record # 2: Documentation on the nursing record in medical record # 2 reflects the use of a vest restraint and four side rails between the hours of 0002 on 08/31/2009 and 1400 on 09/02/2009. The medical record contained two Physician Practitioner Orders Restraint & Management of the Confused or Severely Agitated Patient forms. Two of two forms lacked documentation of any Criteria for Release. One of two forms lacked documentation of Alternative Interventions Attempted or Considered. One of two forms lacked the physician's signature in the box entitled "I concur with the above assessment". One of two forms lacked documentation of the date and time of the physician's signature.

Medical record # 10: Documentation on the nursing record in medical record # 10 reflects the use of a vest restraint and four side rails between the hours of 0930 on 08/31/2009 and 2100 on 09/01/2009. The medical record contained two Physician Practitioner Orders Restraint & Management of the Confused or Severely Agitated Patient forms. One form was dated 08/31/2009 timed 0930 hours. This form lacked documentation of the following: The following Risks (for harm) are Present; Alternative Interventions Attempted or Considered; Criteria for Release; and date/time and authentication by the physician in the box "I concur with the above assessment".

Documentation in the Electronic Medical Record (EMR) nursing record in medical record # 10 reflects the use of the vest restraint on 09/01/2009 between the hours of 0900 and 2100 hours. The medical record lacked an order for the use of restraint on 09/01/2009 between 0900 hours and 2100 hours. The medical record lacked documentation of the renewal of the 08/31/2009 restraint order to continue restraint use after 24 hours and lacked a new order written once each calendar day. The second restraint order form in medical record # 10 was dated 09/03/2009 timed 1300 hours, more than 48 hours after the initial order. This form lacked documentation in the box entitled Criteria for Release and lacked the physician's signature in the box entitled "I concur with the above assessment".

1. Based on the review of medical records, it was determined that in one of six medical records of individuals who were admitted to inpatient hospitalization following the provision of emergency services at the hospital, medical record # 7, the hospital failed to ensure that all drugs and intravenous medications were administered by a Registered Nurse (RN) in accordance with written and signed orders of a physician. Findings:

Documentation in medical record # 7 reflects that Patient # 7 was an 80 year old individual who presented to the Emergency Department at 1630 hours on 08/08/2009 following a ground level fall at home. Documentation on the Emergency Services Patient Record of Treatment reflects that the RN administered the following medications to Patient # 7:
Zofran 4 mg IV at 1645 hours;
Morphine 4 mg IV at 1645 hours and at 1700 hours;
Dilaudid 1 mg IV at 1733 hours, at 1750 hours, and at 1810 hours;
Metoprolol 5 mg IV at 1850 hours; and
Narcan 0.4 mg IV at 2020 hours.

The medical record lacked written and signed physician orders for the medications.

2. Based on the review of medical records, it was determined that in one of two medical records of individuals who received surgical services at the hospital, medical record # 6, the hospital failed to ensure that all drugs and intravenous medications were administered according to accepted standards of practice. Findings:

Documentation in medical record # 6 reflects that Patient # 6 had a wide surgical debridement of a large sacral decubitus on 08/26/2009. The medical record contained a form entitled Physician Practitioner Orders Anesthesia: Pre and Post Operative: For Use in OR, PACU, and SSU only. The form contained a list of drugs used for pain management under the section titled Anesthesia Post-Operative Orders:
Two medications were listed for management of moderate pain:
Fentanyl (Sublimaze) 25-50 mcg IV every 5 min PRN for moderate pain, titrate medication for effective pain control. May repeat to a maximum of 200 mcg; and
Meperidine (Demerol) 25-50 mg IV every 5 min PRN for moderate pain, titrate medication for effective pain control. May repeat to a maximum of 200 mg.

Two medications were listed for management of severe pain:
Morphine 2-6 mg IV every 5 min PRN for severe pain, titrate medication for effective pain control. May repeat to a maximum of 20 mg; and
Hydromorphone (Dilaudid) 0.5 - 1 mg IV every 5 min PRN for severe pain, titrate medication for effective pain control. May repeat to a maximum of 2.5 mg.

The form in medical record # 6 evidenced checkmark in the box that preceded Morphine and Hydromorphone. The orders did not rank the medications as to which medication should be given first and which medication to be given second.

An interview of a representative of the Oregon State Board of Nursing determined that physician/practitioner order forms should be designed and implemented to avoid requiring a nurse to make a judgement as to which medication (or medications) to administer from a menu of medications. The orders should rank the medications as to which medication should be given first, second, etc. and the orders should specify a maximum dose for each medication before administering another medication. The decision to select a drug from a list or menu of drugs is beyond the scope of practice of the Registered Nurse, not in keeping with "prudent, safe, nursing practice standards," and borders on prescriptive responsibilities.