HospitalInspections.org

Based on review of hospital policy, medical record review, observations, and staff interviews, the hospital failed to maintain safety as evidenced by placing a DNR (Do Not Resuscitate--legal order to withhold cardiopulmonary and respiratory efforts on patient after an event of breathing and heart stops) bracelet on a patient's arm with provisions to withhold chest compressions without following policy for 1 of 2 patients. (#9).
The findings include:
Review of the facility policy "Do Not Resuscitate," with revision date of 09/11/2014, revealed "Patients with an order other than DNR (do not resuscitate) do NOT receive a purple armband. When a DNR/DNI (do not resuscitate/do not intubate--withhold the placement of the breathing tube to assist with breathing) combination order is given, the patient care nurse and a second nurse verify the order with patient name and date of birth. Verification documented with the armband in EMR (electronic medical record). Once patient identity is verified by the two nurses, the patient care nurse will place a purple armband on the patient from whom CPR must be withheld."
Open medical record review on 11/12/2015 of patient #9 revealed a 79 year old female admitted on 11/05/2015 with fever of 103 degrees, with admission diagnosis of septicemia (blood infection). Further review revealed a past medical history of non-alcoholic cirrhosis (disease of the liver which may result in terminal illness), hypertension (high blood pressure), and history of closed hip fracture status post hardware removal on October 30, 2015. Further review revealed a physician order written on 11/06/2015 at 2155 for DNR-no chest compressions only. (Do not resuscitate-no attempts to perform chest compressions). Further review revealed no nurses documentation on dates of application of DNR bracelet. Further review of RN #3 notes revealed a purple bracelet was on patient #9 wrist on 11/10/2015 at 1900.
Observation during tour of the ICU (Intensive Care Unit) on 11/12/2015 at 1100 revealed a purple bracelet (indicating DNR order on patient) was on Patient #9's right wrist with 2 signatures (RN #1 and RN #2) written on bracelet.
Interview with AS (administrative assistant) #1 on 11/13/2015 at 1410 revealed the policy was not followed by the two nurses placing the DNR bracelet on the arm of the patient who had provisions to the DNR. Further interview revealed a purple bracelet was placed on patient #9 arm 2 days after the order was written for DNR with chest compressions only. "The DNR bracelet is not supposed to be placed if the DNR order has provisions."

Based upon hospital policy and procedure review, medical record reviews, and staff interviews, the hospital's nursing staff failed to provide ongoing assessment and monitoring of the condition of a patient in restraints in 1 of 4 patients (Patient # 11 ).

The findings include:

Review Policy "Restraint and Seclusion Management Protocol, 2466-1-1, Effective: 5/10/2010, Approved 08/04/2015, Last Revised 08/04/2015, Definitions: A. Physical Restraints: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, leg, body or head freely.... 7. Forensic Restraints: A forensic or correction restraint applied by a correctional/police officer is used for patients under arrest or incarcerated to prevent elopement ( examples: handcuff or ankle cuffs). Forensic restraint devices are monitored by the correctional/police offer and are not the responsibility of ..... Healthcare staff. However, .... staff will assess, monitor and provide safe and appropriate care to the patient according to applicable protocol... NON-VIOLENT OR SELF DESTRUCTIVE BEHAVIOR RESTRAINT (MEDICAL) MANAGEMENT: C. Routine monitoring/Patient Care: ...2. Routine checks will be monitored and documented on initiation and every 2 hours by a staff nurse, NA, or PCT. Routine checks include: psychological status/visual check (i.e. affect/behavior), circulation/skin integrity, ROM, elimination, fluids, and food/meal....."

Closed medical record review on 11/12/2015 of Patient # 11 revealed a 66 year old male who arrived to the facility's emergency department from the DOC (Department of Corrrections) with altered mental status. The patient was admitted with a diagnosed of acute encephalopathy ( swelling of the brain). Record review revealed Patient #11 remained in Forenic (handcuff or ankle cuffs) restraints with his right wrist and left ankle restained. Review of record revealed no documentation of monitoring of the restraints by nursing staff on 10/30/2015 at 1800 through 10/31/2015 at 2000 (14 hours) and on 11/05/2015 at 0400 through 11/05/2015 2000 ( 16 hours).

Interview with Administrative Staff on 11/12/2015 at 1430 revealed no further restraint documentation for Patient #11 was available. Interview confimed facility staff did not follow hospital policy.