HospitalInspections.org

Based on record review, policy review and staff interview, it was determined that the facility failed to obtain appropriate physician order for restraints for 1 (#10) of 10 sampled patients. This practice does not ensure care was provided according to physician orders/

Findings include:

Review of the facility's policy "Restraints Management" #Gn95150 revised 4/08 requires that orders for medical surgical restraints must be renewed every 24 hours. A face to face re-evaluation of the patient by the physician or other designated licensed independent practitioner is also required.

Review of the medical record of patient #10 revealed that a registered nurse (RN) documented a verbal order from the attending physician for soft restraint to be applied to prevent the patient from pulling out medical devices on 1/23/11 at 5:00 p.m. There was no documentation of a re-evaluation having been performed by the attending physician. Nursing documentation revealed that the restraints were maintained until 1/25/11 at 8:00 p.m. The order to continue restraint was not obtained on 1/24/11 as required. A verbal order was written on 1/25/11 at 7;00 p.m. by an RN.

During interview on 1/26/11 at approximately 2:55 p.m., the Nursing Director confirmed that the order was not obtained as required and there was no evidence that the physician performed the required re-evaluation for continuation of the use of restraint.

Based on record review, policy review and staff interview, it was determined that the facility failed to ensure ongoing monitoring of the patient in restraint according to facility policy for 1(#10) of 10 sampled patients.

Findings include:

Review of the medical record of patient #10 revealed the soft wrist restraint was initiated on 1/23/11. Review the medical record revealed that restraints were maintained from 1/23/11 at 5:00 p.m. until 8:00 p.m. on 1/25/11. Review of nursing documentation for monitoring of the patient revealed that the following:
1/23/11 - three hours from initiation of restraint until the first reassessment at 8:00 p.m.
1/24/11 - four hours between assessments. Reassessment at 10:00 a.m. Next reassessment not until 2:00 p.m.
1/24/11 - Fiver hours between assessments. Elimination, nutrition, hydration, privacy and range of motion not assessed from 3:00 p.m. until 8:00 p.m.
1/25/11 - Three hours between assessments. Reassessment at 4:00 a.m., next assessment not until 7:00 a.m.
1/25/11 - The restraint was discontinued at 8:00 p.m. without assessment of the patient's readiness for discontinuation of restraint.

The facility's policy "Restraint Management" #Gn 95150, revised 4/08 requires assessment of the patient in restraint at least every 2 hours. The assessment is to include: sign of injury, respiratory status, color, level of consciousness, symptoms of physical distress, mental status, nutrition/hydration, hygiene, elimination, safety, range of motion (every 4 hours) and readiness for discontinuation of restraint.

During interview on 1/26/11 at approximately 3:25 p.m., the Nursing Director confirmed the nursing staff failed to comply with the facility's policy on monitoring the restrained patient.

Based on record review, policy review and staff interview, it was determined that the facility failed to ensure a Registered Nurse (RN) provided appropriate supervision and evaluation of patient care for assessment and implementation of physician orders for 3 (#1,#3,#6) of 10 sampled patients. This practice does not ensure safe effective care and that patient goals are met.

Findings include:


1. Review of the medical record of patient #1 revealed that he was admitted on 12/4/10 with the chief complaint of chest pain. During the patient's hospitalization a urinary catheter (foley) had been inserted. On 12/5/10 at 6:57 p.m. the physician ordered for "bowel and bladder training every 2 minutes". There was no evidence that the order was clarified. Review of nursing documentation on 12/6/10 at 5:10 a.m. revealed a note that read " started bladder training last night as per order to be done for one day".

On 1/25/11 the Director of Quality Improvement was asked for a copy of the facility's policy on bladder training. The policy "Catheter Camping" # gn95030, reviewed 3/08 states that "foley catheters will be clamped upon physician's order." The policy requires that clamping time should not exceed two hours, followed by unclamping for five to 15 minutes, or as ordered by the physician". It further requires that the time the catheter was clamped and unclamped and the volume of urine obtained after each unclamping was to be documented. The patient's tolerance of the procedure was also to be documented.

Review of he medical record revealed no such documentation. On 12/6/10 at 10:00 a.m. an RN documented that the foley catheter was clamped. A second note was written on 12/6/10, which indicated the foley was removed. There was no documentation of the amount of urine obtained after the foley was unclamped and no documentation that the patient was able to void following removal of the foley. The patient was discharged on 12/6/10 at approximately 4:30 p.m. There was no documented assessment of the patient's urological status.

The Director of Quality confirmed the finding during interview on 1/25/11 at approximately 3:00 p.m. During interview on 1/25/11 at 3:30 p.m. the Chief Nursing Officer also confirmed that the order should have been clarified by both nurses, as it was inappropriate. She also confirmed that the patient should have been assessed following discontinuation of the foley to ensure he was able to void.

2. Review of the medical record of patient #3 revealed the patient was admitted on 1/24/11 with the diagnosis of cerebrovascular accident. The physician wrote an order on 1/25 for neurovascular checks every 4 hours. Review of documentation of patient assessment revealed that the assessments performed on 1/26/11 at midnight, 2:00 a.m. and 4:00 a.m. did not include assessment of upper and lower extremely capillary refill as required.

The staff nurse present at the time of record review on 1/26/11 at approximately 2:45 p.m. confirmed the assessments were incomplete.

3. Patient #6 was admitted on 1/22/11 with the diagnosis of cellulitis of the face and end stage renal disease (ESRD). The physician wrote an order to monitor intake and output on 1/22/11. Review of the medical record revealed that there was no documentation of intake and output on 1/22/11, 1/23/11 and 1/24/11. In addition, meal consumption was not documented for all meals on 1/22/11 and 1/23/11.

The Nursing Director confirmed the findings on 1/26/11 at approximately 11:15 a.m.