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A. Based on a review of Hospital policy and procedure, medical record review and staff interview, it was determined that in 1 of 2 (Pt #'s 11) medical records reviewed after 5/26/11 in which patients were put into restraints for promotion of medical healing and/or safety, the Hospital failed to ensure that patients were monitored as indicated per Hospital policy.

Findings include:

1. The Hospital policy and procedure titled, "Utilization of Restraints & Seclusion" was reviewed on 7/14/11. It indicated under, "Orders: For patients in restraints for promotion/maintenance of medical surgical healing...Patients being restrained to promote/maintain medical surgical healing will be monitored, with documentation, every 30
for the first hour and every two hours there after or more frequently as necessary to adequately reflect the patients condition and to protect safety and dignity."

2. The medical record of Pt #'s 11 was reviewed on 7/14/11. Pt. #11 was admitted to the Hospital on 5/29/11 with the diagnosis of Delirium Tremens. Pt. #11 was placed in soft wrist restraints in the Emergency Department at 11:30 AM. Documentation on the " Daily Seclusion and Flow Sheet" indicated that Vital Signs (VS) were completed on 5/29/11 at 12:02 PM. Documentation indicated that VS were taken the next time at 7:50 PM. Documentation indicated VS were taken on 5/30/11 at 8:00 AM and 11:33 AM.

3. During an interview conducted on 7/14/11 at 2:00 PM with the Director of Risk Management & Regulatory Preparedness, the above finding was confirmed.

A. Based on Hospital policy and procedure, medical record review and staff interview it was determined in 1 of 13 (Pt. #1) medical records reviewed that the Hospital failed to ensure that pain was assessed and effectiveness of medications were documented per policy.

Findings include:

1. The Hospital policy titled "Pain Management" under "D. Pain assessment will occur at a minimum of once per shift. Patients will be reassessed after administration of pain medications within a time consistent within the anticipated onset of effect of the specific medication administered." was reviewed on 7/14/11.

2. The medical record of Pt. #1 was reviewed on7/14/11. Pt. #1 was admitted to the Hospital on 2/3/11 with the diagnosis of Closed Rib Fracture-2 Ribs. Documentation indicated that on 2/5/11 Pt. #1 complained of pain at 1600 and Tylenol was given. There was no documentation to indicate that the nurse reassessed Pt. #1 until 1900. At 1900 patient was still having pain. Documentation on the Medication Administration Record (MAR) indicated that Tramadol 50 mg po was given at 1515 and 2245. There was no documentation to indicate that the nurse reassessed for effectiveness of pain medication. On 2/6/11 the MAR indicated that Acetaminophen 650 mg po was given at 0840, there was no documention the nurse reassessed for effectiveness of pain medication.

3. During an interview conducted on 7/14/11 at 3:00 PM with the Director of Risk Management and Regulatory Preparedness, the above finding was confirmed.

A. Based on medical record review and staff interview, it was determined in 1 of 13 (Pt. #1) medical records reviewed, the Hospital failed to ensure that all drugs were administered as ordered by the physician.

Findings include:

1. The medical record of Pt. #1 was reviewed on 7/14/11. Pt. #1 was admitted to the Hospital on 2/3/11 with the diagnosis of Closed Rib Fracture-2 Ribs. Documentation indicated the physician ordered Valium 5mg X 1 IM on 2/4/11. Nursing documentation on the Medication Administration Record (MAR) on 2/4/11 at 1525 indicated Valium 5mg X 1 IM "did not give not needed." There was no documentation in the medical record to indicate the nurse notified the physician that the medication was not given as ordered.

2 . During an interview conducted on 7/14/11 at 3:00 PM with the Director of Risk Management and Regulatory Preparedness, the above finding was confirmed.

A. Based on medical record review and staff interview it was determined in 1 of 13 (Pt. #1) medical records reviewed the Hospital failed to ensure all medications were recorded in a consistent and legible manner in which staff are able to identify the time of what medication was or was not taken in order to monitor the patient's condition and provide appropriate care.

Findings include:

1. The medical record of Pt. #1 was reviewed on7/14/11. Pt. #1 was admitted to the Hospital on 2/3/11 with the diagnosis of Closed Rib Fracture-2 Ribs. Documentation indicated a Late Entry on 2/5/11 at 0746 in the "List Patient Notes" that Pt. #1 "complains of side pain , medicated with PRN meds with relief." Documentation indicated that on 2/5/11 at 1600 patient states "having pain in her right ribs and would like something. Tylenol given." The Medication Administration Record (MAR) indicated that Acetaminophen 650 mg was given on 2/5/11 at 0840 and appears to be 1700(documentation illegible) and Tramadol 50 mg po was given at appears to be 1515 (documentation illegible) and 2245. The times in the "List Patient Notes" and the MAR do not coincide. "List Patient Notes" documentation on 2/6/11 at 1711 indicated that "Pt. medicated with Tylenol 650 mg" . There was no documentation on the MAR that Tylenol was given.

2 . During an interview conducted on 7/14/11 at 3:00 PM with the Director of Risk Management and Regulatory Preparedness, the above finding was confirmed.