HospitalInspections.org

Based on review of hospital policy/procedure, hospital document, medical records and interview, it was determined that the hospital failed to require that a physician or other licensed independent practitioner (LIP) conduct and document, within 1 hour after the initiation of restraint, a face to face evaluation of patients restrained for the management of violent or self-destructive behavior which includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraint for 2 of 2 patients (Pts # 1 and 2).

Findings include:

Review of the hospital policy/procedure titled Restraints revealed:...Violent/Self Destructive (Behavioral Restraint) or Seclusion...Physician Order:...the physician must see the patient face-to-face within one hour...A registered nurse may initiate restraint or seclusion in advance of the physician's order...One hour face-to-face assessment: The physician shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of the restraint to determine if clinically indicated and if other factors, such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis, etc., are contributing to the patient's violent or self-destructive behavior. The physician will evaluate:...The patient's immediate situation...The patient's reaction to the intervention...the patient's medical and behavioral condition; and...The need to continue or terminate the restraint or seclusion...."

Review of the hospital form titled Restraint Orders: Violent/Self Destructive revealed that it contained a statement located above the spaces designated for documentation of a Telephone Order, Nurse Signature, Physician Authentication of Order and Physician Signature: "...Confirm Restraint Justification:...By ordering the initiation of restraints, I confirm alternative methods have been tried and found ineffective, the use of restraints is clinically indicated for this patient and found to be the least restrictive measure that meets the patient's clinical needs and protects the safety of the patient and others. The face-to-face evaluation has been completed and has included an evaluation of the patient's immediate situation, the patient's reaction to the intervention and a physical and behavioral assessment of the patient. The evaluation of the patient's medical condition has included a complete review of systems assessment, behavioral assessment, a review and assessment of the patient's history, drugs and medications and most recent lab results. Other factors, such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis, have been assessed to determine if they are contributing to the patient's violent or self-destructive behavior. (Note the Initial face to face valuation (sic) must take place within 1 hour of restraint application)...."

Pt #1 was admitted to the Emergency Department (ED) on 8/4/12. An RN documented at 0243 that the patient was placed in "B-4" and was "...tearful, crying and angry about being here...." The medical record contained documentation of the MD evaluation time at 0327. An RN documented that the MD was at the patient's bedside at 0410 for "initial exam." An RN documented at 0545: "...Pt yelling (at) staff. Holding pencil in threatening manner. Pencil taken from pt. attempted to take clipboard. pt fighting for clipboard & pushing staff...Pt into 4 point restraints for (increased) safety...."

At 0730, an RN documented: "...Pt resting quietly in bed. Restraints X 4 (4 point) in place...pt voiced understanding of criteria for removal of restraints...0800...Pt is calm...Restraints removed...."

Pt #1's medical record contained the form Restraint Orders: Violent/Self Destructive, signed by a physician on 8/4/12, at 0555. The medical record did not contain documentation of the physician's face-to-face evaluation of the patient completed within 1 hour after initiation of the restraints.

Pt #2 was admitted to the Intensive Care Unit (ICU) via the ED on 8/6/12, due to a change in mental status. His medical record contained the form Restraint Orders: Violent/Self Destructive, with nursing documentation: "...Indication of the Need for Restraints...punching kicking staff...." An RN signed the form on 8/6/12 at 1345. A physician signed the form on 8/6/12 at 1400. The medical record contained documentation that the patient was in 4-point soft restraints from 1400 until 2000, when they were discontinued.

Pt #2's medical record did not contain documentation of the physician's face-to-face evaluation of the patient completed within 1 hour after initiation of the restraints.

The Chief Quality Officer confirmed during an interview conducted on 8/9/12, that the medical records of Pts #1 and #2 did not contain documentation of the physician's face-to-face evaluation of the patients completed within 1 hour after the initiation of restraints as required.

Based on review of hospital policies/procedures, hospital documents, medical records and interviews, it was determined that the hospital failed to require that an RN administer medications in accordance with the orders of the practitioner or practitioners responsible for the patient's care and hospital policy for 3 of 3 patients who were sedated via continuous titrated intravenous infusion (Pts #3, 4 and 5).

Findings include:

Review of hospital policy/procedure titled Continuous Infusion Dosing and Titration Protocol revealed: "...Policy: Medications administered by continuous infusion are dosed and titrated in a safe, effective manner...Purpose: To standardize continuous infusion dosing when 'per protocol' dosing is ordered by the physician...."

Review of hospital policy/procedure titled Continuous Sedation Infusion for Mechanically Ventilated Patients Protocol revealed: "...Physician orders Midazolam, Propofol, or Lorazepam 'per Sedation Protocol'...Nurse initiates and titrates ordered medication...."

Review of hospital form titled Continuous Sedation Infusion Orders for Mechanically Ventilated Patients Per Protocol revealed: "...Initiate and titrate ordered medication as described below...Obtain a separate physician or LIP (Licensed Independent Practitioner) order for any protocol deviations...Goals: Sedation score of 3 (mild sedation (anxiolysis), occasionally sleeping, easy to arouse, responds to verbal stimuli) or below and Agitation score of 0 (calm and cooperative)...."

Review of hospital form titled Continuous Opioid Analgesic Infusion Orders per Protocol revealed: "...Initiate and titrate ordered medication as described below...obtain a separate physician or LIP order for any protocol deviations...."

Review of medical records revealed:

Pt #3 was admitted to the hospital on 7/20/12 via the ED due to altered mental status and nosebleed. He required intubation due to his inability to protect his own airway. An RN documented Propofol infusion at 10 mcg/Kg/min from 1415 on 7/20/12, until 7/21/12 at 1045, when it was "off."

On 7/21/12 at 0400, an RN recorded a physician's verbal order: "...Diprivan GTT (drip)-continue and titrate per protocol...." The medical record did not contain a physician's order for Diprivan on 7/20/12.

On 8/9/12, the Chief Quality Officer confirmed that an RN documented administration of Intravenous (IV) infusion of Propofol (Diprivan) without a physician's order.

Pt #4 was admitted to the hospital on 7/22/12 via the ED due to "...Syncope, Hypotension, Acute on chronic renal failure (and) Questionable CVA (Cerebral Vascular Accident.)...."

On 7/23/12 at 2130, a physician wrote orders: "...Vent per Hospitalist...Meds...versed gtt...." The order did not contain reference to a protocol. Pt #4's medical record contained the form titled Continuous Sedation Infusion Protocol for Orders for Mechanically Ventilated Patients per Protocol, signed by an RN on 7/23/12 at 2200. The box next to the Midazolam (Versed) contained an X mark.

(Refer to information regarding Pt #5 for contents of Versed protocol orders.)

The RN recorded Pt #4's Versed infusion, starting at 2215 on 7/23/12, at a rate of 4 mg/hr.

On 8/9/12, the ICU Educator confirmed that the physician's order for "Versed gtt" did not reference the protocol as required and the RN did not have an order to implement the protocol or Versed infusion as documented.

Pt #5 was admitted to the hospital on 7/21/12; transferred from another hospital's ED due to status epilepticus. He had been intubated and was on Fentanyl and Versed at the time of his arrival.

On 7/21/12 at 0147, an RN documented a physician's telephone order: "...Versed gtt per protocol...Fentanyl gtt per protocol...."

Pt #5's medical record contained a form titled Continuous Sedation Infusion Orders for Mechanically Ventilated Patients per Protocol. The box next to Midazolam (Versed) contained an X mark: "...Midazolam (Versed)...Bolus 1 mg IV push every 2 minutes up to 5 mg, then begin Midazolam infusion at 2 mg/hour...Titrate infusion by 0.5mg/hour to 2mg/hour until sedation/agitation goal is achieved...Repeat bolus dosing as above for acute agitation (i.e. agitation score 1 or above) before increasing infusion...Maximum infusion dose: 20mg/hour...Call physician after continuous infusion duration of 48 hours...." The margin next to the Midazolam section contained handwriting: "infusing on transfer from (name of hospital) (at) 2 mg/hr...." The form was signed by an RN on 7/21/12 at 0147. The medical record did not contain a separate physician order for the deviation from the protocol.

Pt #5's medical record also contained a form titled Continuous Opioid Analgesic Infusion Orders per Protocol: The box next to Fentanyl (Sublimaze) contained an X mark: "...Bolus IV push only if ordered, then begin Fentanyl infusion at 10 mcg/hour...Titrate infusion by 10 mcg/hour until pain goal is achieved...Maximum infusion dose: 200 mcg/hour...." The margin next to the Fentanyl section contained handwriting: "...infusing on transfer from (name of hospital) (at) 50 mcg/hr...." The form was signed by an RN on 7/21/12 at 0147. The medical record did not contain a separate physician order for the deviation from the protocol.

Pt #5's medical record contained documentation that the RN recorded the infusion of Versed on 7/21/12 at 0137, at 2 mg/hr. The RN titrated the dose to 5 mg/hr from 0145 until 0215, when the RN reduced the dose to 4 mg/hr from 0215 through 0330, when s/he increased the dose to 5 mg/hr. The RN continued the Versed infusion at varying doses until 7/22/12 at 0800, when it was "off."

The RN recorded Pt #5's Fentanyl infusion on 7/21/12 at 0137 at 50 mcg/hr. until 0230 when the RN reduced the dose to 25 mcg/hr. The RN continued the Fentanyl infusion until 7/21/21 at 0400, when it was "off."

The Chief Nursing Officer confirmed during interview conducted on 8/9/12, that the RN administered the Versed and Fentanyl infusions at a dosage and rate which deviated from the respective protocols and s/he did not obtain separate physician's orders as required.