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Based on record reviews, interview, and review of the hospital's policy and procedure, the hospital failed to ensure physician orders for restraint procedures are secured timely without the use of standing orders, protocols, and existing orders when patients required restraints for 4 of 9 patient charts with restraints ordered as an intervention. (Patient #12, #13, #14, and #15)

The findings are:

Patient #15
On 7/14/2021 at 10:24 AM, review of Patient #15's chart revealed the Registered Nurse(RN) documented the patient was placed in restraints on 07/10/2021 at 10:00 PM, but the physician order for the restraints was dated 7/11/2021 at 12:18 AM. The Registered Nurse documented the restraint orders as "ordered per protocol" on 7/11/2021 at 12:18 AM, on 7/12/2021 at 7:02 AM, and on 7/14/2021 at 8:01 AM. The findings were verified by Manager #16 at 10:24 AM on 7/14/2021. The findings were verified by Registered Nurse #1 at 2:06 PM on 7/16/2021.

Patient #13
On 7/14/2021 at 11:29 AM, review of Patient #13's chart revealed the Registered Nurse documented the orders for the patient's restraints as "ordered per protocol" on 7/10/2021 at 6:28 PM and on 7/14/2021 at 7:53 AM. The finding was verified by Clinical Practice Specialist #1 at 11:29 AM on 7/14/2021.

Patient #12
On 7/14/2021 at 2:52 PM, review of Patient 12's chart revealed the Registered Nurse documented orders for the patient's restraints as "per standing order" or "per protocol" or "existing order" on 6/7/2021 at 4:16 PM, on 6/9/2021 at 11:50 PM, on 6/13/2021 at 1:57 PM, on 6/15/2021 at 7:54 PM, on 6/15/2021 at 8:41 PM, on 6/17/2021 at 11:11 PM, on 6/18/2021 at 11:23 PM, on 6/20/2021 at 3:44 AM, on 6/21/2021 at 11:21 PM, on 6/22/2021 at 11:30 PM, on 6/25/2021 at 12:36 AM, on 6/25/2021 at 9:40 AM, on 6/28/2021 at 6:55 AM, on 6/29/2021 at 6:21 AM, on 7/1/2021 at 6:45 AM, on 7/8/2021 at 12:38 AM, on 7/8/2021 at 7:58 PM, and on 7/9/2021 at 8:08 PM. The findings were verified by Clinical Practice Specialist #1 at 2:52 PM on 7/14/2021.

Patient #14
On 7/15/2021 at 11:27 AM, review of Patient 14's chart revealed the Registered Nurse documented the order for bilateral soft wrist restraints (non-violent or non-self-destructive) for the patient on 7/10/2021 at 7:15 AM as "within the scope of practice". Hospital restraint policy, reads "orders for restraints expire the next calendar day" at 11:59 PM. Documentation on 07/11/2021 at 07:12 AM revealed the order for the restraint was discontinued. The finding was verified by Clinical Practice Specialist #1 and Director #1 on 7/15/2021 at 11:27 AM.

Hospital policy and procedure, titled, "Restraint and Seclusion", stated, "To ensure the safety of the non-violent, non-self-destructive patient each order for restraints must be renewed each calendar day. .....Standing orders, as needed or PRN orders for restraints are not acceptable."

Based on record reviews, interviews, and review of the hospital's policy and procedure, the Registered Nurse (RN) failed to document the patient's vital signs(Temperature, Blood Pressure, Respirations, and Pulse) on initiation of the patient's blood transfusion, at fifteen to twenty minutes after initiation of the patient's blood transfusion, and/or at the completion of the patient's blood transfusion per hospital policy for 5 of 31 patient charts reviewed for assessments requiring the patient's vital signs.
(Patient #12, #25, #26, #28, and #29)

The findings are:

Patient #12
On 7/14/2021 at 2:52 PM, review of Patient 12's chart revealed a blood transfusion was initiated for the patient on 6/14/2021 at 12:05 PM and was completed at 6/14/2021 at 1:29 PM. Vital signs documented for the fifteen to twenty minute check only included a pulse and blood pressure at 12:12 PM, for vital signs at 12:30 PM, and when the blood transfusion was completed at 1:29 PM. On 7/5/2021, a blood transfusion was initiated at 10:32 AM and completed on 7/5/2021 at 4:47 PM. [sic] At 10:00 AM, a blood pressure, pulse, and respiration was documented. At 10:30 AM, a blood pressure and temperature was documented. At 10:45 AM, only a blood pressure was documented. The findings were verified by Clinical Practice Specialist #1 at 2:52 PM on 7/14/2021.

Patient #25
On 7/15/2021 at 2:27 PM, review of Patient 25's chart revealed the patient's blood transfusion was initiated on 7/10/2021 at 10:34 PM but the vital signs documented at 10:34 PM had no temperature documented. The findings were verified by Clinical Practice Specialist #1 at 2:27 PM on 7/15/2021.

Patient #26
On 7/15/2021 at 1:35 PM, review of Patient #26's chart revealed the patient was admitted on 7/10/2021 with a diagnosis of motor vehicle accident and received four units of blood on 7/11/2021. Documentation showed the second unit of blood was started at 10:24 AM and completed at 10:45 AM. No vital signs were documented at 10:24 AM or at 10:45 AM. At 10:00 AM, a blood pressure, heart rate, and respirations were documented, but no temperature was documented. A blood pressure only was documented at 10:30 AM. The fourth unit of blood was started on 11:26 PM but no vital signs were documented. The findings were verified by Clinical Practice Specialist #1 and Director #1 on 7/15/2021 at 1:35 PM.

On 7/15/2021 at 10:58 AM, a review of the hospital's guidelines for blood and blood product transfusion states "Vital signs should be taken and documented immediately prior to or upon starting the infusion, within fifteen to twenty minutes after starting the transfusion, and upon completion of the infusion". The findings were verified by Director #3 at 10:58 AM on 7/15/2021.


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Patient #28
On 7/15/21 at 11:15 AM, review of Patient #28's chart revealed the patient was admitted on 5/27/21 due to a motorcycle accident with multiple injuries. On 5/31/21 at 7:50 PM, the patient received a unit of packed red blood cells. There was no documentation that vital signs were obtained prior to administering the blood to the patient. The findings were verified by Clinical Practice Specialist (CPS) 3 at the time of review.

Patient #29
On 7/15/21 at 9:50 AM, review of Patient #29's chart revealed the patient was admitted on 4/8/21 with a diagnosis of cardiac arrest. On 4/24/21 at 2:46 PM, a unit packed red blood cells was initiated. There was no temperature documented prior to administering the blood, and only the patient's blood pressure was documented at 2:45 PM. The findings were verified by Clinical Practice Specialist (CPS) 3 at the time of review.

Based on record reviews, interviews, and review of the hospital's policies and procedures, 5 of 31 patient chart reviews revealed the staff failed to follow the hospital's policies and procedures for assessment and documenting of the patients vital signs when the patient is receiving blood transfusions. (Patient #12, #25, #26, #28, and #29)

The findings are:

Cross Reference to A 0392: The Registered Nurse (RN) failed to document the patient's vital signs(Temperature, Blood Pressure, Respirations, and Pulse) on initiation of the patient's blood transfusion, at fifteen to twenty minutes after initiation of the patient's blood transfusion, and/or at the completion of the patient's blood transfusion per hospital policy for 5 of 31 patient charts reviewed for assessments requiring the patient's vital signs