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Based on a review of facility documents, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that orders were written for the use of restraints for two of five medical records reviewed (MR11 and MR 15).

Findings include:

A review of the facility's "Physical Restraints/Seclusion" policy, last reviewed April 1, 2014, revealed "... 2. Restraint Order Guidelines. A. Initiation of Physical Restraint for Non-Violent Behavior... II. Order to Initiate the Use of Physical Restraint for Non-Violent Behavior. a. The registered nurse initiating the use of the physical restraint will immediately obtain an order for the use of Physical Restraint for Non-Violent Behavior Order Form-INV 14712. b. A LIP will place a written order for the use of physical restraint in the individual's medical record as soon as possible. If the LIP is not the attending/primary physician, the individual's attending/primary physician will be notified as soon as possible that an order was obtained for the use of the physical restraint. c. Standing and PRN orders will not be used. d. An LIP will complete an in-person evaluation of the individual within 24 hours of the initiation of physical restraint. III. Order to Continue the use of Physical Restraint for Non-Violent Behavior. a. A licensed independent practitioner will determine the clinically justified need to continue the use of physical restraint by issuing a new order and completing an in-person reevaluation of the individual once every 24 hours."

A review on June 4, 2014, of MR11 revealed that the patient was placed in bilateral soft wrist restraints for non-violent behavior from February 8, 2014, at 6:00 AM until February 12, 2014, at 2:00 PM. The record further revealed that no physican order was obtained to initiate the use of the physical restraint and that no new order was obtained to continue the use of the physical restraint every 24 hours.

A review on June 4, 2014, of MR15 revealed that the patient was placed in bilateral soft wrist restraints for non-violent behavior from February 8, 2014, at 5:00 AM until February 10, 2014, at 12:00 AM. The record further revealed that no physican order was obtained to initiate the use of the physical restraint and that no new order was obtained to continue the use of the physical restraint every 24 hours.

An interview conducted on June 4, 2014, at 1:45 PM with EMP5 confirmed that no physician order was obtained to initiate the use of the physical restraints for MR 11 and MR15 and that no new order was obtained to continue the use of the physical restraints every 24 hours for MR 11 and MR 15.

Based on a review of facility documents, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that new orders were written for the continued use of restraints for management of violent behavior every four hours for one of five medical records reviewed (MR12).

Findings include:

A review of the facility's "Physical Restraints/Seclusion" policy, last reviewed April 1, 2014, revealed "... 2. Restraint Order Guidelines... III. Order to Continue the Use of Physical Restraint/Seclusion for Violent Behavior. a. The decision to continue the use of physical restraint/seclusion will be made by a LIP in collaboration with a qualified RN and will be based on the individual's ability to achieve behavioral criteria documented on the Restraint/Seclusion for Violent Behavior Order Sheet or Progress Notes. b. Orders to continue the use of physical restraint/seclusion are time limited and must be obtained once every: i. 4 hours for the individual who is 18 years and older..."

A review June 4, 2014, of MR12 revealed that the patient was over the age of 18 and was placed in bilateral soft wrist restraints for violent behavior from February 23, 2014, at 9:45 PM until February 25, 2014, at 9:00 AM. The medical record further revealed that three physician's orders were obtained for the use of bilateral wrist restraints for violent behavior: one on February 24, 2014, at 9:45 PM; a second order on February 24, 2014, at 4:20 AM; and a third order on February 25, 2014, at 9:00 AM. The medical record also revealed that no new order for the continued use of the physical restraint for violent behavior was obtained every four hours.

An interview conducted on June 4, 2014, at 1:45 PM with EMP5 confirmed that MR12 contained no new physician order for the continued use of the physical restraint for violent behavior every four hours.

Based on a review of facility policy, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that the patient was correctly identified prior to the administration of drugs for one of 23 medical records reviewed(MR23).

Findings include:

A review on June 2, 2014, of facility policy Pinnacle Health Hospitals Operations Manual, revealed, Subject: Patient Identification, Policy Statement: It is the policy of Pinnacle Health Hospitals to identify patients prior to providing care, treatment, or services. In keeping with the Joint Commission and other national safety practices ... Procedure Guidelines: 1. All patients presenting for treatment provide verification of their name and date of birth along with a written physician's order (if applicable) ...Whenever possible. Palm Vein software is used to identify patient and pull appropriate medical record up in Soarian Financial's. If patient is currently not enrolled, all patients presenting for treatment will provide picture identification if at all possible ... III. Before any procedure is carried out the identification arm band or face sheet must be checked by the responsible care provider for the following two identifiers to ensure that the right patient is involved: A. Patient name. B. Patient date of birth ... IV. Whenever possible the staff should also verbally confirm the patient's identification by asking the patient's name and date of birth and matching the verbal confirmation to the information on the identification arm band or face sheet ..."

A review on June 2, 2014, of MR23 revealed the patient was admitted on May 27, 2014. The review of the Pinnacle Health Harrisburg Campus Emergency Record revealed "Patient (name redacted), DOB 12/31/1957. MedRec XXXX3951 ... Nursing Procedure: Bedside Radiology: Portable chest x-ray performed. Nursing Procedure: Bedside Testing: Patient Identifier: Patient's identity verified by patient stating name, Patient's identify verified by patient stating birth date, Patient's identify verified by hospital bracelet ... Medication Service: Heparin (porcine) Inj: Order heparin ( porcine) Inj (heparin sodium, porcine) - dose 5000 units(s) : IV Bolus ... Patient, medication, Dose, Route and time verified prior to administration ... Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medication reviewed prior to administration ... morphine Inj: Order: morphine Inj (morphine sulfate) - dose: 4 mg; IV... Plavix: Order: Plavix ( Clopidogrel bisulfate) - Dose 300 mg: oral ... Patient, Medication, Dose, Route and Time verified prior to administration. Site: Medication administered P.O., correct patient, time, route, dose, and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration. Allergies confirmed and medication reviewed prior to administration ... sodium chloride 0.9% IV: Order sodium chloride 0.9% IV Dose 500 ml: IV Bolus ... Patient Medication, Dose, Route, and Time verified prior to administration ... Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of action and side - effects prior to administration, Allergies confirmed and medications reviewed prior to administration ... Orders: Basic Metabolic Panel, CBC and Diff, Chest (one view), CK, Total W/ CKMB Iso, EKG, IV- Insert 2 Large Bore IV, Lab Bedside: I Stat BMP, Lab Bedside: I Stat Troponin, Prothrombin Time, PTT, Troponin I Quantitative ..."
Further review of the medical record revealed the patient was taken for a heart catherization. The review of the Pinnacle Health Heart and Vascular Institute documentation revealed "Patient name (name redacted) Study date 5/27/2014, MR XXXXX7542 ... Comments: Pt is a code Stemi from the ER will answer questions at a later date ... Event Log ... 12:01:07 PM Patent on Table, questions answered, prepped for procedure; 12:01:07 PM Pt identified by Dr (name redacted); Pt identified by (name redacted); H&P on chart; Informed consent obtained ... 12:05:13 PM SpO2 96%; HR 99 bpm; 106/73/87 NBP; LOC 2; RR 25/min. Pt arrived to CCL1 Emergently voices he is pain free at the time of arrival will continue to monitor and assess the pt. ...12:11:13 PM "Time Out" process completed ..."

An interview conducted on June 2, 2014, at 11:15 AM with EMP3 confirmed that the patient had an x-ray, EKG, blood work drawn, and medication administered in the Emergency Department without staff verbally confirming the date of birth with the patient. The facility did not follow their policy in identifying the patient.

An interview conducted on June 2, 2014, at 2:10 PM with EMP9 confirmed that all staff were involved in the heart catheterization time out and that the patient was awake at the beginning of the time out and did not indicate that it was not the patient's date of birth.
EMP9 confirmed that the facility did not follow their policy to confirm the date of birth to identify the patient prior to the administration of drugs.

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