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Based on a review of medical records, review of the facility's policy and procedures and interview with administrative staff, it was determined the facility failed to have a physician's order for restraints every 24 hours. This effected Medical Record (MR) # 10 and had the potential to negatively effect all patients requiring restraints.


Findings include:


Safety Policy- Restraints
Date Issued: June 1983
Date Revised: 8/30/00

I. Restraints including limb holders, restraining jackets, and body restraints are used for:

6. The restraint order will be a 24-hour stop order. If the restraints are removed for longer than body comforts, then reapplied, the order must be rewritten.

7. The restraint order will not be a PRN (as needed) order.

Procedure:

5. The maximum length of time between between observing the patient in restraints is every 2 hours...Documentation will be made on the patients circulation, condition of the skin and limbs, attention to hydration, feeding, toilet, range of motion, and general condition as resting, still agitated, etc. the patient will be offered personal hygiene needs, nutritional needs as well as emotional and comfort needs. The restraint flow sheet will be used to document. Numbers 1, 2, and 3 must be filled out completely on the flow sheet.


1. Medical Record # 10 was admitted to the facility on 2/21/12 with the diagnoses of Congestive Heart Failure and Pulmonary Insuffiency. A review of the medical record and physician's orders revealed there was no orders written every 24 hours for the continued use of restraints. Review of an initial physician's verbal order written on 02/22/12 at 00:22 hours and signed by the physician at 06:00 hours. The next order was written by the physician on 2/22/12 at 06:00 hours for soft wrist restraints. Review of the nurse notes revealed the patient was restrained from 2/22/12 through 3/1/12. There was no order 2/24/12 or 2/28/12 at 06:00 hours and there was no documentation the restraints had been removed during the period of time without the written orders.

The only documentation contained on the Restraint Flow Sheet was as follows:

2/28/12 - 0600 hours to 1700 hours, and 3/1/12 - 0600 hours to 1300 hours.

Review of the Patient Progress Notes dated 2/22/12 through 3/1/12 revealed the Skilled Nurse documented the release/ discontinuation of the restraints were "unsuccessful".

An interview conducted 7/4/12 at 4:00 PM with Employee Identifier (EI) # 1, Registered Nurse, Bachelors Science Nursing, verified there was no other orders or restraint flow sheets.

Based on medical record review, hospital policy review and staff interview, it was determined the hospital failed to ensure orders for the use of restraints were not written on an as needed basis (PRN) for 1 of 2 patients with restraint orders. This affected medical record (MR) # 12 and had the potential to affect all patients served at the hospital.

Findings include:


Safety Policy- Restraints
Date Issued: June 1983
Date Revised: 8/30/00, 06/20/2006

I. Restraints including limb holders, restraining jackets, and body restraints are used for:


7. The restraint order will not be a PRN (as needed) order.

8. The order includes clinical justification, time limit not to exceed 24-hours and type of restraint.


1. MR # 12 was admitted to the hospital on 3/10/12 with diagnoses including Mental Status Change, Metastatic Cancer and Shortness of Breath.

Review of the physician's orders revealed the following orders written on 3/10/12: "....Restraints as necessary for Pt (patient) security/safety...." This was a PRN order and also did not contain the type of restraint that was to be used.

During an interview on 7/4/12 at 10:25 AM, Employee Identifier (EI) # 1, Registered Nurse, Bachelors Science Nursing, confirmed the restraint order was not specific as to the type of restraint that was to be used and that the order was a PRN order. EI # 1 confirmed the restraint order should not have been written as a PRN order.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on medical record review, hospital policy review, review of the hospital Designated Requestor Training Sign-In Sheet and staff interview, it was determined the hospital failed to ensure the staff member who initiated the request for organ procurement followed the hospital policy in 1 of 2 records with Routine Referral Donor Forms and failed to ensure the staff member had been formally trained in the donation process. This affected medical record (MR) # 12 and had the potential to affect all patients who expired at this facility.


Findings include:

Policy
Referral to Alabama Organ Center (AOC)
Issued 2/22/99
Revised 11/29/00
Statement of Purpose: Referring all deaths to the Alabama Organ Center

Text:

1. Following any death ....The Alabama Organ Center must be notified. (use the form designated for this purpose: "Routine Referral Donor Form").
2. The AOC Representative will determine donor suitability. If the patient is not medically suitable for organ or tissue donation, you call will be forwarded to the AEB (Alabama Eye Bank) for evalouations. If the patient is not a candidate for donation, document the reason given by the AOC/AEB Representative on the form.

3. If the patient is a suitable candidate, the "Designated Requestor" (the nurse) initiates the steps for consent and the family either accepts or declines the opportunity for the patient to be a candidate.

4. Document the family member approached and the response. If there is any conflict within the family, notify the AOC........

1. MR # 12 was admitted to the hospital on 3/10/12 with diagnoses including Mental Status Change, Metastatic Cancer and Shortness of Breath. The patient's condition declined and the patient expired on 3/12/12.

Review of the medical record revealed Employee Identifier (EI) # 2, Registered Nurse (RN), made the following entries in the medical record on 3/12/12:

07:15 (7:15 AM).....amended 8:59 AM..."Pt's (patient's) wife approached concerning organ donation. Wife declines stating that it was not her husband's wish."

07:30 (7:30 AM)..."Alabama Eye Bank notified of pt's (patient's) death and family's decline to donate. Spoke with......Alabama Organ Center also notitied (notified) of pt's death and of pt's decline to donate......"


There was no documentation EI # 2 contacted the AOC/AEB to determine donor suitability prior to approaching the patient's family regarding the patient being a donor. There was no documentation that EI # 2 followed the hospital's AOC referral policy.

Review of the Routine Referral Donor Form revealed EI # 2 did not complete Step 1: Evaluate the Patient, Step 2: Call the AOC/AEB Simultaneously or Step 3: Document Donor Suitability sections of the Routine Referral Donor Form.

Review of the Designator Requestor Training Sign-In Sheet for 11/12/09 revealed EI # 2 did not attend the training. Review of EI # 2's personnel file revealed no documentation that EI # 2 had been trained as a Desingated Requestor for Organ Donations.


During an interview on 7/14/12 at 12:35 PM, EI # 1, RN/Bachelor Science of Nursing (BS), confirmed EI # 2 was not trained to be a designated requestor for Organ Donations and did not follow their policy for referral to AOC.

Based on record review, hospital policy review and interviews, it was determined the facility failed to follow their emergency department (ED) policy for reporting dog bites to the proper authorities for 2 of 2 emergency room patients admitted with dog bites. This affected emergency room records (ER) # 1 and # 2 and had the potential to affect all patients who presented to the ED with animal bites.

Findings include:

Policy: Reporting Animal Bites
Date Issued: 2/94
Date Revised: 10/2000, 9/2009

Statement of Purpose: Establish guidelines to fulfill County Health Department requirements on animal bites treated at Wiregrass Medical Center.

Text:
1. All animal bites are to be reported to the appropriate County Health Department.

2. Utilize "Animal Bite Report" from the appropriate County Health Department.

3. Forms should be completed with as much detail as possible.

4. When forms are completed they must be faxed to the appropriate County Health Department ....

5. Documentation is the medical record should include:
a. Form completed
b. Faxed to County Health Department (include which health
department)
c. Form scanned into CPSI
d. Form and fax confirmation sheet placed in medical record


1. ER # 7 was admitted to the ED on 3/3/12 with a diagnosis of dog bite. Review of the ED record revealed no documentation the incident was reported to the county health department or the form titled "Animal Bite Report/ Rabies Investigation" was completed as stated in the policy.

2. ER # 8 was admitted to the ED on 3/8/12 with a diagnosis of dog bite. Review of the ED record revealed no documentation the incident was reported to the county health department or the form titled "Animal Bite Report/ Rabies Investigation" was completed as stated in the policy.

An interview on 7/4/12 at 4:00 PM with Employee Identifier # 1, Registered Nurse, Bachelor Science Nursing, confirmed the two incidents were not reported to the county health department or the form titled "Animal Bite Report/ Rabies Investigation" was completed as stated in the policy.