HospitalInspections.org

Based on hospital policy review, medical record review, and staff interview, the hospital failed to ensure the use of patient restraint was in accordance with the order of a licensed medical provider on 1 of 11 patients (Patient #1).

Findings include:

Review of hospital policy titled Restraint Utilization for Acute Medical-Surgical (non-violent) Indications Procedure, effective date 10/31/2012, revealed, "... -All restraint orders will be renewed daily based on the patient's assessed needs, (renewal at least every 24 hours between 0600 and 0900, is preferred) as determined via a Physician's, NP's, or PA's face-to-face assessment, will be clinically justified, and will be time-limited..."

Closed medical record review of Patient (PT) #1 revealed an order, written by Medical Doctor (MD) #1 on 05/28/2015 at 15:36, for, "Restraints non-violent or non-self destructive." Further record review revealed the order expired on 05/29/2015 at 15:36. Further review revealed PT #1's bilateral soft wrist restraints were removed at 05/29/2015 at 22:00 hours, 6 hours and 24 minutes after the order had expired.

Staff interview was conducted on 06/03/2015 at 12:29, with the Accreditation RN (Registered Nurse), who stated hospital policy was not followed for non-violent restraints on PT #1.

NC00103782

Based on hospital policy review, record review, and staff interview, the hospital failed to administer blood products in accordance with the approved medical staff policies and procedures on 2 of 11 patients (Patients #8 and #9).

Findings include:

Review of hospital policy titled Blood Product Administration Policy, effective date 04/29/2015, revealed, "...All blood product components will be scanned into the electronic medical record and validated that information is correct... 1. Documentation in the EMR (Electronic Medical Record)... c. Blood product infusion link to IV site. d. Record volume of blood product transfused."

1. Record review of the closed medical record of Patient (PT) #8 revealed administration of 2 units of Packed Red Blood Cells (PRBCs) on 05/05/2015 at 08:08 and 12:34. Further review revealed no documentation of an existing IV site during hospital admission, and no documentation of volume of blood product transfused for either transfusion.

Staff interview was conducted on 06/04/2015 at 11:30, with Registered Nurse (RN) #1, who stated facility staff did not follow hospital policy for documentation of blood transfusions.

2. Record review of the closed medical record of PT #9 revealed administration of 2 units of PBRCs on 05/01/2015 at 20:00 and 23:43. Further review revealed no documentation of volume of blood product transfused for either transfusion.

Staff interview was conducted on 06/04/2015 at 11:30, with RN #1, who stated facility staff did not follow hospital policy for documentation of blood transfusions.

NC00103782