HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 10 (Pt #2) patients reviewed for patient rights, the Hospital failed to ensure that family or legal guardian was notified of a patient's admission in a timely manner.

Findings include:

1. The Hospital's policy titled, "Patient Rights and Responsibilities" (revision date 8/2019), was reviewed on 10/6/2020, and required, "...It is the policy of [Hospital] to recognize and respect the rights of all patients...As a patient of [Hospital], you have a right to: 3. Have a support person (as determined by you while following confidentiality rules and regulations) and/or physician notified of your admission..."

2. The clinical record for Pt #2 was reviewed on 10/5/2020. Pt #2 presented to the ED (emergency department) on 9/14/2020 at 7:23 AM with seizures, with a past medical history of DD [developmental delay], seizures, and down syndrome. Pt. #2 was non-verbal upon admission. Pt #2's Medical Surgical Admission Data Form (to the the Medical/Surgical Unit), dated 9/14/20 at 10:15 AM, indicated that the Legal Guardian listed was not notified of Pt #2's admission. The nurse's note, dated 9/14/2020 at 6:00 PM, included that the [Legal Guardian] was notified at that time (10 hrs and 37 minutes after admission).

3. On 10/6/2020 at 11:05 AM, an interview was conducted with the LCSW (E #4/Licensed Clinical Social Worker). E #4 stated that Pt #2's mother was his legal guardian. E #4 stated that it is both the transferring facility and the Hospital's responsibility to notify the family or legal guardian of a patient's admission as soon as possible.

Based on document review and interview, it was determined that for 1 of 4 (Pt #2) clinical records reviewed for restraints, the Hospital failed to ensure that the least restrictive measure was utilized prior to placing a patient in restraints.

Findings include:

1. The Hospital's policy titled, "Restraint/Seclusion" (revision date 1/2019), was reviewed on 10/6/2020, and required, "...Conversely, clinically and developmentally appropriate alternatives to restraint are to be attempted, documented and found to be ineffective prior to use of restraint if possible...The type of restraint is limited to the least restrictive device possible."

2. The Hospital's policy titled, "Patient Safety Attendant (PSA) and Remote Companions (revision date 3/21/2020), was reviewed on 10/6/2020, and required, "The purpose of this policy is to ensure the safety of patient (s) from harming themselves and or/or others. There are instances when patients who are at risk patients that are high risk for fall or injury...D. Indicators for initiation of constant observation status by a patient safety attendant for risk of fall or injury may include: 1. Patients at risk for fall; 2. Patients who are confused, have impaired judgement. and at risk for complicating their medical condition..."

3. The clinical record of Pt # 2 was reviewed on 10/5/2020. Pt #2 presented to the ED (emergency department) on 9/14/2020 at 7:23 AM, with an admitting diagnosis of seizures.

- Pt #2's Fall Risk Assessment, documented by E #3 (dated 9/14/2020 at 10:00 AM), indicated that Pt #2's fall risk score was 70 (high risk).

- A Nurse's Note (dated 9/14/2020 at 3:00 PM), included, "Restraints applied pt keeps getting up from bed."

- Restraint/Initiation/Notifications (dated 9/14/2020 at 4:00 PM), indicated that right and left wrist restraints and a vest restraint were applied to the patient. The reason for the application of the restraint was to prevent unintentional injury or harm.

- The Progress Note, documented by the Physician Assistant (PA #1), dated 9/15/2020 at 9:03 AM, included, " ...Had two seizures yesterday lasting around 10 seconds per RN [registered nurse]. Also had unwitnessed fall yesterday, found on the ground next to his bed. Now in restraints ..."

The clinical record indicated that no less restrictive methods, including a safety attendant, were attempted prior to placing Pt, #2 in restraints.

4. On 10/7/2020 at 8:50 AM, an interview was conducted with the Medical/Surgical Registered Nurse (E#3/nurse caring for Pt #2 on the unit). E #3 stated that Pt #2 came in due to seizures and had two witnessed seizures on the unit. Pt #2 stated that the patient was attempting to get out of bed and fell. E #3 stated that she placed wrists restraints and a vest restraint on Pt. #2 at some time between 3:00 PM and 4:00 PM. E #3 stated that Pt #2 did not have a sitter (PSA). E #3 stated that with Pt #2 being a high risk for falls, a sitter would have been warranted. E #3 stated that it is not standard practice to restrain a patient with seizures.

5. On 10/6/2020 at 10:30 AM, an interview was conducted with the Medical/Surgical Unit Manager (E #8). E #8 stated that the least restrictive measures should be attempted prior to initiating a restraint. E #8 stated that if restraints are used, the least restrictive device should be used first. E#8 listed the order from least to most restrictive restraints as mitts (not tied to the bed), wrist restraints, and then Posey vest (most restrictive). E #8 stated that restraining a patient with a Posey Vest, while they are having seizures, could cause serious harm by restricting their breathing. E #8 stated that if a patient is on seizure and fall precautions, they should have a sitter. E #8 stated that the nurses should call the House Supervisor to request a sitter.

Based on document review and interview, it was determined that for 1 of 4 (Pt #2) clinical records reviewed for restraints, the Hospital failed to ensure that patients in restraints were monitored at least every two hours, as required.

Findings include:

1. The Hospital's policy titled, "Restraint Policy", (revision date 1/2019), was reviewed on 10/6/2020, and required, "Monitoring and assessment will consist of safety checks...Non-violent, non-self destructive: 1. The patient shall be monitored at regular intervals, at least 2 hours, to be determined consistent with physician orders and/or patient condition..."

2. The clinical record of Pt # 2 was reviewed on 10/5/2020. Pt #2 presented to the ED (emergency department) on 9/14/2020 at 7:23 AM, with an admitting diagnosis of seizures.

- Restraint/Initiation/Notifications (dated 9/14/2020 at 4:00 PM), indicated that right and left wrist restraints and a vest restraint were applied to the patient. The reason for the application of the restraints was to prevent unintentional injury or harm. The record indicated that Pt. #2 remained in restraints until 9/17/2020 at 4:00 PM.

- Pt #2's clinical record lacked documentation of restraint assessments and/or monitoring from 9/16/2020 at 6:00 PM through 9/17/2020 at 8:00 AM (14-hour time frame).

3. On 10/6/2020 at 10:30 AM, an interview was conducted with the Medical/Surgical Unit Manager (E #8). E #8 stated that the nursing staff are required to do assessments on patients in non-violent restraints every two hours.

4. On 10/7/2020 at 8:50 AM, an interview was conducted with a Medical/Surgical Registered Nurse. E #3 stated that restraint documentation should be done every two hours for non-violent restraints.