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Based on interview and medical record review, the hospital failed to ensure the patient's family was notified of the use of restraints as per the hospital's P&P for one of nine sampled patients (Patient 2). This failure had the potential for depriving the family of the opportunity to participate in the decisions about the patient's care.

Findings:

Review of the hospital's P&P titled Restraints: Non-Violent Behavior dated 3/16/23, showed the patient and family are educated as possible as to the purpose for restraint use, criteria for termination, and monitoring and care that will be provided. Documentation includes pertinent information including physician and family notification.

On 2/20/24 at 1037 hours, an interview and concurrent review of Patient 2's medical record was conducted with the Director of Telemetry and DOU.

Patient 2's medical record showed Patient 2 was admitted to the hospital on 2/13/24.

Review of the nursing assessment dated 2/14/23 at 2000 hours, showed Patient 2 was confused but oriented to person.

Review of the physician's order dated 2/15/24 at 0112 hours, showed to apply the soft restraints to Patient 2's right and left upper extremities.

However, further review of Patient 2' medical record failed to show documentation Patient 2's family was informed of the use of restraints.

On 2/20/24 at 1037 hours, an interview and concurrent medical record review was conducted with the Director of Telemetry and DOU. The Director of Telemetry and DOU was informed and acknowledged the findings.

Based on observation, interview, and record review, the hospital failed to ensure the Contract Employee Dialysis Nurse properly wore a gown when entering the patient's room as per the hospital's P&P for one of nine sampled patients (Patient 4). This failure created the risk of the spread of infection to the patients in the hospital.

Findings:

Review of hospital's P&P titled Clostridium difficile (C. difficile) Prevention Bundle dated 9/21/23, showed all patients who are suspected of having CDI or confirmed as having active infection with C. difficile will be placed on contact plus precautions. The gown and gloves are required when entering the room.

Review of Patient 4's medical record was initiated on 2/20/24. Patient 4's medical record showed Patient 4 was admitted to the hospital on 2/16/24.

Review of the physician's order dated 2/18/24 at 1958 hours, showed to place the patient on contact isolation to rule out C. difficile. The healthcare personnel caring for the patients on contact precaution wore a gown and gloves for all interactions that might involve contact with the patient or potentially contaminated areas in the patient environment and donning the PPE upon the room entry and discarding it before exiting the patient room is required.

During a concurrent observation and interview on 2/20/24 at 1011 hours, with the CNO, the Contract Employee Dialysis Nurse was observed outside Patient 4's room. A signage was observed posted outside of Patient 4's room showing Contact Enteric Isolation and to wear gown and gloves. An isolation cart was observed containing available PPE, including yellow-colored gown and gloves. A yellow-colored gown was observed with two securing ties, one at the top for behind the neck and one at the waist. The Contract Employee Dialysis Nurse was observed being in the patient room and wearing the yellow-colored gown without the top tie secured behind the neck secured. The lower tie at the waist was observed to be tied and secured. The front of the yellow-colored gown was observed falling forward, exposing the underneath clothing/uniform of the Contract Employee Dialysis Nurse.

On 2/20/24 at 1018 hours, an interview was conducted with the CNO. The CNO confirmed the observation of the Contract Employee Dialysis Nurse who wore a the yellow-colored gown with the unsecured top tie. The CNO stated the expectation was for all care providers including contract employees who entered a patient's room with Contact Precaution signage were to don and doff the PPE correctly based on the signage posted outside the room. The CNO stated the hospital did not train the contract employees on donning and doffing the PPE but did expect the contract agency to train them.

On 2/20/24 at 1028 hours, an interview was conducted with the Contract Employee Dialysis Nurse. The Contract Employee Dialysis Nurse verified she was providing the hemodialysis treatment to Patient 4 in the patient's room. The Contract Employee Dialysis Nurse stated she was aware of the signage showing Contact Enteric Isolation. The Contract Employee Dialysis Nurse verified the Contract Employee Dialysis Nurse knew the PPE was required to don and doff when entering and exiting Patient 4's room. The Contract Employee Dialysis Nurse stated she knew the yellow-colored gown needed to be tied and secured at both her neck and waist. The Contract Employee Dialysis Nurse stated the purpose of correctly donning PPE was for safety to both the patient and caregiver. Securing the yellow-colored gown at the top was done to prevent exposure of the caregiver's clothes/uniform underneath. The Contract Employee Dialysis Nurse verified she had tied and secured the yellow-colored gown only at the waist and not the top tie for the neck.

On 2/21/24 at 1308 hours, an interview was conducted with the Infection Preventionist. The Infection Preventionist stated the purpose of PPE was to protect the caregivers, staff, and patients from the spread of infection. The Infection Preventionist stated the PPE was expected to be donned correctly prior to entering a patient's room based on the type of isolation. The Infection Preventionist stated the type of isolation signage was posted outside of the patient's room. The Infection Preventionist stated the expectation for the caregivers was to don and wear the yellow-colored gowns with both ties affixed and secured at the neck and waist. The purpose for tying and securing both the top and waist ties on the yellow-colored gown was to protect the caregivers clothing beneath and prevent the spread of the organism. The Infection Preventionist stated the expectation applied to anyone who was entering an isolation room including the staff, contract employees, visitors, and family of the patients on isolation.

On 2/23/24 at 1200 hours, the CNO was made aware of the findings.

Based on interview and record review, the hospital failed to ensure a physician's order for the use of non-violent soft restraints was renewed as per the hospital's P&P for one of nine sampled patient (Patient 2). This failure had the potential for unnecessary use of restraints.

Findings:

Review of the hospital's P&P titled Restraints: Non-Violent Behavior dated 3/16/23, showed a written order based on an examination of the patient by the physician is entered into the patient's medical record within 24 hours of the initiation of the restraints. Continued use of restraint beyond the first 24 hours is authorized by the physician after the examination of the patient and renewing the original order or issuing a new order. This is done no less than once each calendar day.

On 2/20/24 at 1037 hours, an interview and concurrent review of Patient 2's medical record was conducted with the Director of Telemetry and DOU.

Patient 2's medical record showed Patient 2 was admitted to the hospital on 2/13/24.

Review of the physician's order dated 2/16/24 at 1132 hours, showed to apply the soft restraints to Patient 2's right and left upper extremities. Further review of the physician's order showed the duration should not exceed 24 hours or one day, and the orders must be renewed every calendar day or when discontinued.

Review of Patient 2's restraint flowsheet showed the soft restraints to the left and right wrists were continued for the patient from 2/17/24 1200 hours to 2/17/25 2200 hours.

Review of the physician's order dated 2/17/24 at 2205 hours, showed to apply the soft restraints to Patient 2's right and left upper extremities.

There was no documented evidence to show the physician's order was obtained or renewed for the use of soft restraints for Patient 2 when it was exceeding 24 hours or every calendar day as per the hospital's P&P.

The Director of Telemetry and DOU was informed and acknowledged the findings.

Based on observation, interview, and record review, the hospital failed to ensure the nursing staff monitored the use of non-violent restraints every two hours for one of nine sampled patients (Patient 5). This failure placed the patient at risk for not receiving the appropriate care to prevent possible medical complications.

Findings:

Review of hospital's P&P titled Restraints: Non-Violent Behavior dated 3/16/23, showed a patient in restraints is to be monitored at least every two hours or more often as applicable to the patient. Monitoring is accomplished by observation and interaction with the patient or related direct examination of the patient by qualified staff. The care provided to the patients in restraints include toileting, positioning, circulation checks, range of motion and food/fluids to be offered. Documentation includes to use the restraint order form, electronic medical record restraint flowsheet, and narrative notes to document all pertinent information in the patient's medical record, including assessments, care provided, and monitoring activities.

During an observation on 2/20/24 at 1035 hours with the CNO, Patient 5 was observed on bilateral wrist restraints.

Review of Patient 5's medical record was initiated on 2/20/24. Patient 5's medical record showed the patient was admitted to the hospital on 2/16/24.

Review of the physician's order dated 2/19/24 at 1853 hours, showed to apply the soft restraints to the patient's bilateral wrists. The reason for the restraints was interference with the medical treatment. The patient pulled out his NGT and needed the restraints.

Review of Patient 5's restraint flowsheet showed Patient 5 was restrained on 2/19/24 at 1853 hours. Patient 5 was provided with care on 2/19/24 at 2000, 2200, and 2346 hours; and on 2/20/24 at 0800 hours. There was no documented evidence to show monitoring and nursing care were provided to Patient 5 at least every two hours from 2/19/24 at 2347 hours to 2/20/24) at 0759 hours (approximately 8 hours), as per the hospital's P&P.

On 2/20/24 at 1240 hours, an interview and concurrent review of Patient 5's medical record was conducted with the CNO. The CNO reviewed and verified the hospital's P&P titled Restraints: Non-violent Behavior applied to Patient 5's care. The CNO stated the expectation was for the nursing staff to follow the hospital's P&P to monitor and provide the nursing care at least every two hours to the patients who were restrained. The CNO stated the nurse was expected to monitor and offer care such as toileting, repositioning, checking the patient's circulation, and offering nutrition and fluid to the patients who were restrained. The CNO stated the nurse was expected to document the care provided to the patients in the patients' medical records. The CNO reviewed Patient 5's medical record and verified there was no documentation to show Patient 5 was monitored or provided care from 2/19/24 at 2347 hours to 2/20/24 at 0759 hours.

Based on interview and record review, the hospital failed to ensure the nursing staff conducted the pain reassessment after administering the pain medication as per the hospital's P&P for one of nine sampled patients (Patient 6). This failure had the potential to result in poor health outcomes to the patients.

Findings:

Review of hospital's P&P titled Pain Management dated 06/29/21, showed the hospital places emphasis on pain management, including comfort, managing side effects, complications, and patient satisfaction. Patient participation in pain management is imperative and expected. The single most reliable indicator of existence and intensity of pain is the patient's self-report. The section for Procedure showed to assess for pain using a pain scale with each new report of pain and after each pain management intervention once sufficient time has elapsed for treatment to reach peak effect. The goal is reassessment and documentation within one hour of intervention. Documentation should include patient's response to the intervention.

Review of Patient 6's medical record was initiated on 2/20/24. Patient 6's medical record showed the patient was admitted to the hospital on 2/19/24.

Review of the Plan of Care dated 2/20/24 at 1010 hours, showed the patient's problem was pain. The goal was for the patient's pain to be manageable. The plan was to assess and monitor the patient's pain levels using the appropriate pain scale, initiate the plan and interventions as ordered, re-assess the patient's pain levels 30 to 60 minutes after the pain management intervention.

Review of the physician's order dated 2/19/24 at 2359 hours, showed to administer hydrocodone-acetaminophen 5-325 mg (an opioid pain medication) one tablet orally every six hours as needed for moderate pain (the pain level would be from four to six), and severe pain (the pain level would be from seven to 10).

On 2/20/24 at 0938 hours, an interview was conducted with Patient 6. Patient 6 stated Patient 6 had been having pain in her arm and had told the nurse about the pain but had not received any pain medication.

Review of Patient 6's MAR showed hydrocodone-acetaminophen 5-325 mg was administered to the patient on 2/20/24 at 1201 hours.

Review of Patient 6's pain assessment showed on 2/20/24 at 1201 hours, Patient 6's pain level was 10 out of 10.

Further review of Patient 6's pain assessment did not show the nursing staff had conducted any pain reassessment for Patient 6 on 2/20/24 at 1300 hours or 1400 hours.

On 2/20/24 at 1420 hours, an interview and concurrent medical record review was conducted with the CNO. The CNO reviewed and verified the hospital's P&P titled Pain Management applied to the care for Patient 6. The CNO stated the expectation was for the nursing staff to follow the hospital's P&P to treat and reassess the patient's pain. The CNO stated Patient 6 was assessed for pain using the 0 to 10 pain scale (with 0 = no pain and 10 = worst pain). The CNO stated the nursing staff was to reassess the patient's pain in one hour to after providing the treatment to the patient. The rationale was to assess the effectiveness of the treatment. The CNO reviewed and verified Patient 6 was assessed for pain and treated with medication on 2/20/24 at 1201 hours. The CNO reviewed and verified on 2/20/24 at 1420 hours, Patient 6's pain had not been reassessed for the treatment effectiveness.